
Uass___L^_ 

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U.S. ^ift^-i^W c *f4 



Manual of Instructions for 
Medical Advisory Boards 



Prescribed by the President under the authority 
vested in him by the terms of the Selective 
Service Law (Act of Congress ap- 
proved May 18, 1917) 



Office of the Provost Marshal General 
Form 64 




Washington 

Government Printing Office 

i918 



D. of D. 

APR 22 1918 



t .A* 



War Department, 

Washington, Ufii day of February, 191&. 
Under the authority vested in him by the Act of Congress, May 
18, 1917, the President of the United States prescribes this Manual 
of Instructions for Medical Advisory Boards, prepared under the 
direction of the Surgeon General of the Army, and directs that they 
be published for the government of all concerned, and that they be 
strictly observed. 

Newton D. Baker, 

Secretary of War. 



in 



MANUAL OF INSTRUCTIONS FOR MEDICAL 
ADVISORY BOARDS. 



REGULATIONS FOR THE PHYSICAL EXAMINATION OF REG- 
ISTRANTS REFERRED TO THE MEDICAL ADVISORY 
BOARDS. 

CONTENTS. 

Page. 

I. Preliminary statement ]-12 

II. Place, order, and method of examination 12, 13 

Special examinations and standards for unconditional rejection, 
unconditional acceptance, with or without remediable defects. 

III . Mental and nervous 13-17 

IV. Skin 17-19 

V. Head 19, 20 

VI . Spine 20-23 

VII. Ears, and test for hearing and malingering 23-26 

VIII . Eyes, and tests for vision and malingering 26-33 

IX. Mouth, nose, fauces, pharynx, larynx, trachea, and esophagus 33-36 

X. Neck— Goiter 37-40 

XI. Lungs and chest 40-50 

XII. Heart and blood vessels 50-57 

XIII. Abdomen — Hernia and gastro-intestinal examination 57-74 

XIV. Anus and hemorrhoids 74, 75 

XV. Genito-urinary organs and venereal diseases 75-81 

XVI. Affections common to both extremities 81-84 

XVII. Upper extremities and hands 84, 85 

XVIII. Lower extremities and feet 85, 86 

XIX. Height, weight, and chest measurements 87, 88 

XX. Dental requirements 89, 90 

XXI. General 90, 91 

XXII. General notes on malingering 91-97 

XXIII. Degree of deficiency for disqualification 97 

XXIV. Temporary defects 97-99 

XXV. Special and limited military service 99 

XXVI. Appendix: Rules of Procedure. Essential sections of Selective Serv- 
ice Regulations 99-112 

1 



2 

I. PRELIMINARY STATEMENT. 
Functions of Medical Advisory Boards. 

Medical Advisory Boards have no power to determine 
finally whether a registrant shall he accepted or rejected 
for military service. This power is placed hy the Selective 
Service Law in the Local and District Boards of Exemp- 
tion. The functions of the Medical Advisory Boards are, 
as the name imports, to examine registrants referred to 
them hy the Exemption Boards and State Adjutants 
General, and to return the result of their examinations, 
inserted at the proper places in Form 1010 P. M. G. O., 
"Report of Physical Examination" (section 282, Selec- 
tive-Service Regulations, page 155). 

Section 44, S. S. R., states the functions of Medical 
Advisory Boards as follows: 

There have been provided in the various counties, cities, and other 
localities throughout the United Statea, Medical Advisory Boards, who 
will examine registrants sent to them by Local Boards or State Adju- 
tants General for examination, and will advise such Local Boards or 
State Adjutants General concerning the physical condition of such 
registrants. Upon the advice so obtained, Local Boards may proceed 
to a final determination concerning the physical qualifications of such 
registrants. 

This MANUAL OF INSTRUCTIONS FOR MEDICAL 
ADVISORY BOARDS is not part of the Selective-Service 
Regulations, hut consists of the enunciation of rules and 
standards which are to govern Medical Advisory Boards 
in making their examinations and arriving at their 
opinions concerning the physical and mental qualifica- 
tions of registrants, and in conducting their husiness and 
transmitting their reports, advice, and recommendations. 

Certain sections of the Selective- Service Regu- 
lations relating to and governing the action and 
procedure of Medical Advisory Boards, together 
with rules of organization and procedure, are 
printed as an appendix at the end of this Manual, 
for convenient reference. They must be carefully 
read and observed. 

The Selective-Service Regulations contains, as an 
integral part thereof, namely Part VIII (sections 182 to 
188, inclusive), regulations governing physical examina- 
tion of registrants by the examining physicians of Local 
Boards. For convenience of the Medical Advisory 
Boards these regulations governing Local Board's physi- 
cal examinations are reprinted, in appropriate places 



throughout this Manual, in order that Medical Advisory 
Boards may be fully advised concerning the standards 
of acceptance and rejection by examining physicians 
of Local Boards and concerning the regulations requiring 
the reference of doubtful and remediable cases to the 
Medical Advisory Boards. 

From the foregoing it is apparent that the injunctions 
herein contained to accept or reject registrants, or to 
place them in certain groups in accordance with their 
respective physical qualifications, is not to be taken as 
importing that the action of Medical Advisory Boards is 
final. But these Instructions are rules and standards 
to guide Medical Advisory Boards in arriving at their 
decisions and in formulating their reports of their exami- 
nations on Form 1010. 

This MANUAL OF INSTRUCTIONS FOE MEDICAL 
ADVISORY BOARDS has been prepared by a board of 
qualified specialists, including military surgeons, ap- 
pointed by the Surgeon General; and the rules and 
standards herein set forth relating to examinations by 
the examining physicians of Local Boards, as well as 
by the Medical Advisory Boards, are based upon the 
same rules and standards that are to be followed by the 
military examining surgeons at cantonments or recruit- 
ing stations. In this manner it is expected that no 
registrants found by the boards to be qualified for 
military service will be rejected upon their subsequent 
examination by the examining surgeons at the camps. 

Distribution of Registrants into Four General Grouos. 

Section 128 J of the Selective-Service Regulations pro- 
vides as follows: 

The Regulations (Part VIII) governing physical 
examinations by Local Boards prescribe a stand- 
ard of unconditional acceptance and a standard 
of unconditional rejection. All cases found, upon 
physical examination by a Local Board, falling 
between these two standards shall be referred 
by the Local Board to the Medical Advisory Board 
in the same manner as other cases that are re- 
quired by these regulations so to be referred. 
Cases so referred as falling between these two 
standards, and cases referred to Medical Advisory 
Boards under other provisions of these regula- 
tions, shall be examined by the Medical Advisory 



Boards, who, after examination in accordance 
with the Manual of Instructions for Medical 
Advisory Boards (Form 64, P. M. G. 0.), shall: 

A. Accept the registrant as physically quali- 
fied for general military service; or, 

B. Accept the registrant as physically quali- 
fied for general military service when cured 

of (naming a remediable defect for 

which acceptance is authorized in the Manual 
of Instructions for Medical Advisory Boards, 
Form 64, P. M. G. 0.) ; or, 

C. Accept the registrant as physically quali- 
fied for special or limited military service in a 
named occupation or capacity; or, 

D. Reject the registrant; 

and shall record their finding in the proper 
spaces provided on Form 1010. 

Medical Advisory Boards shall find a registrant 
physically qualified for general military service 
(Rule A above) only when he falls within the 
standard of unconditional acceptance as pre- 
scribed in Sections 182 to 188, inclusive, as fur- 
ther explained and amplified by the Manual of 
Instructions for Medical Advisory Boards (Form 
64, P. M. G. 0.), including cases of slight remedi- 
able defects not included under foregoing Rule B. 

Medical Advisory Boards shall find a registrant 
physically qualified for general military service 
WHEN CURED OF A REMEDIABLE DEFECT 
(Rule B above) only in those cases when such 
acceptance is specifically authorized in the Man- 
ual of Instructions for Medical Advisory Boards 
(Form 64, P. M. G. 0.); namely, when a regis- 
trant is found to fall within the "deferred reme- 
diable group." 

When a Medical Advisory Board determines that 
a registrant should be accepted for general mili- 
tary service WHEN CURED OF SUCH REME- 
DIABLE DEFECTS (Rule B above) the Medical 
Advisory Board shall insert in ink in the space 
provided on page 2 of Form 1010, under the gen- 
eral heading "PHYSICAL EXAMINATION BY 
MEDICAL ADVISORY BOARD," and following 
the words "Physically qualified for general mili- 
tary service," the words "when cured of — 



99 



followed by the name or diagnosis of the remedia- 
ble defect, which name or diagnosis is to be fol- 
lowed by a circle in black ink. Upon return to 
the Local Board of the record (Form 1010) in such 
a case, and if the finding of the Medical Advisory 
Board is confirmed by the Local Board, the regis- 
trant's place in the classification column shall not 
be changed, but the Local Board shall, WITH 
BLACK INK, inscribe a bold circle around the 
cross mark (X) or cipher (0) in such classification 
column; and such registrant shall be inducted 
into military service, after his order number is 
reached, and at such time as may be designated 
by the Surgeon General of the Army, and shall 
be sent to cantonment base hospitals, recon- 
struction camps, or civic general hospitals as 
may be determined by the Surgeon General. 

Registrants shall be found by Medical Advisory 
Boards as "physically qualified for special or 
limited military service" (Rule C above) only in 
those cases described in the Manual of Instruc- 
tions for Medical Advisory Boards (Form 64 
P. M. G. 0.), and in such cases the Medical Ad- 
visory Boards shall designate the occupation or 
class of service for which such persons are physi- 
cally qualified in the space provided on page 2, under 
the general heading "PHYSICAL EXAMINATION 
BY MEDICAL ADVISORY BOARD" (Form 1010 
P. M. G. O.), after the words "physically qualified 

for special or limited military service as" . 

If such finding is confirmed by the Local Board the 
same shall be indicated on the Classification List 
as provided by section 124. 

Registrants shall be found by Medical Advisory 
Boards as physically deficient and not physically 
qualified for military service (Rule D above) only 
when they fall within the standards of uncon- 
ditional rejections as prescribed in sections 182 
to 188, inclusive, as further explained and amplified 
by the Manual of Instructions for Medical Ad- 
visory Boards (Form 64 P. M. G. O.). 

When a Medical Advisory Board delays the exami- 
nation of a registrant on account of temporary 
defect it must return to the proper Local Board 
form 1010 with a statement attached thereto 



(but not written thereon), stating the reason for 
delay, and fixing a definite period of time within 
which the registrant shall be sent back to it. At 
the end of said period, or earlier, if it believe the 
temporary defect is removed, the Local Board 
shall send the registrant back to the Medical 
Advisory Board, unless the Local Board believes 
that the examination should be further delayed, 
in which event it shall report the facts upon which 
its belief is based to the Medical Advisory Board 
and request its instructions. 

The foregoing regulation, quoted from the Selective- 
Service Regulations, clearly indicates the four groups 
into which Medical Advisory Boards shall place registranst 
as a result of the physical examinations in accordance 
with this Manual of Instructions. 

Further Instructions and Explanation as to Groups. 

In other words Group A shall contain registrants found 
to be qualified for general military service within the 
standards of unconditional acceptance, including regis- 
trants with slight remediable defects; for example, a 
registrant who, under examination of the nose, is found 
to have: " Benign growth of any kind, nasal polypi, 
hypertrophy of the mucous membrane, benign superficial 
ulcerations, deviation of the septum." And for a further 
example: " Registrants with single or multiple lesions of 
the skin of a nonmalignant character which, in the 
judgment of the Medical Advisory Board, are remediable 
by treatment." And for a further example: "Regis- 
trants with benign tumors of the neck." 

Registrants with such slight remediable defects shall 
be held physically qualified for general military service, 
the defects to be remedied after the registrant enters the 
cantonment (if not remedied pending orders) . 

All registrants coming within the foregoing definition 
and as specifically indicated in the instructions in this 
Manual, are to be included in Group A and reported as 
physically qualified for general military service in the 
place indicated on Form 1010. 

Group B shall contain registrants who are found to 
be physically qualified for general military service when 
cured of some remediable defect, which is of such a char- 
acter that it must be remedied or cured before the regis- 
trant can be ordered to camp. This group is called 



"the deferred remediable group." It includes regis- 
trants who have incapacitating but remediable defects. 
Such defects will be remedied, when the registrant is 
calledj in such hospitals as may be designated by the 
Surgeon General. In this group "the deferred reme- 
diable group," will be placed registrants suffering, for 
example, "with large hernia," with trachoma, from 
drug addiction, "with large remediable ulcers," "with 
the lesion of the skin distinctly malignant, apparently 
curable," registrants suffering with conjunctivitis and 
other specially mentioned diseases of the eyes. 

Registrants placed in this group will be reported as 
"physically qualified for general military service when 
cured of " (the name or diagnosis of the reme- 
diable defect), and shall be reported on Form 1010 in 
the manner provided in section 128J, S. S. R., above 
quoted. 

Group C shall contain registrants who are found to 
be not within the standard of unconditional acceptance 
on account of defects which are not remediable, nor 
sufficiently incapacitating to bring them within the con- 
dition of unconditional rejection. This is the group of 
registrants who may be found to be qualified for spec- 
ial or limited military service. For example, registrants 
who are suffering "with ankylosis of the lower jaw, per- 
forations of the hard palate, registrants who do not have 
the minimum dental requirements" for general military 
service nor for placing in Group B, but who are physi- 
cally qualified in other respects, and this without regard 
to the condition or absence of all teeth, etc. Regis- 
trants in this group shall be reported on Form 1010, as 
provided in foregoing section 128 J, S. S. R., for special 
or limited military service in the particular occupation 
or capacity which must be named in the report. 

Group D shall contain all registrants coming within the 
standards of unconditional rejection and includes all 
cases not included in Groups A, B, and C. Such regis- 
trants must be reported on Form 1010 as "physically de- 
ficient and not physically qualified for military service by 

reason of " (the reason for the disqualification to 

be stated in the blank provided). 

In arriving at their decisions concerning the physical 
qualifications of registrants, Medical Advisory Boards 
must be governed, as to the grouping of registrants, by 
the specific instructions contained in this Manual. 



8 

Bieadquarters. Headquarters, Expenses, Correspondence. 

Medical Advisory Boards must conduct all their 
proceedings in strict accordance with these regu- 
lations and the Selective-Service Regulations, and 
at the headquarters of the Board. 

No physical examination, nor any part thereof, 
shall be conducted elsewhere (and especially not 
at the private office of a member of the Board) 
except in case of absolute necessity and for the 
purpose of utilizing apparatus which is not avail- 
able elsewhere. 
Expenses. Applications for authority to incur clerical and all 

other expenses (including such expenses as payment for 
materials in X-ray work, etc.) must be made, before the 
expense is incurred, to the Governor. (See sections 
43(d), 198, 204 and 208 S. S. K. printed in the appendix.) 

All inquiries, requests for interpretations, reports, and 
Correspondence, communications of every character (except those with 
Local Boards) must be addressed to the Governor or State 
Adjutant General, either directly or through the Medical 
Aide to the Governor. When necessary such communica- 
tions will be forwarded tnrough proper channels to the 
Surgeon General. (See sec. 25, S. S. R., printed in the 
appendix.) 

Regulation for Local Board. (Section 182 S. S. R.) 

^Form: See sec. j n v i ew f the contemplation of a further investiga- 
tion and classification of registrants physically qualified 
for special and limited military service who have not 
the physical qualifications for general military service, 
and in view of the decision to accept some registrants 
for general military service with remediable defects, who 
are otherwise physically and mentally qualified for mili- 
tary service, the following new regulations for the 
physical examination of registrants by the physician on 
the Local Board become necessary. 
Acceptance, Local Boards can accept registrants for general mili- 

general service. ( . . 

tary service only when they come within the standards 
for unconditional acceptance with or without remediable 
defects. 
teSserS' gen " Local Boards can reject registrants for general mili- 
tary service only when the registrant comes within the 
standards of unconditional rejection. 



All other registrants must be referred by the Local other cases. 
Board to the Medical Advisory Board for further ex- 
amination and classification. 

Physicians on the Local Board are not required to re j5fcn. ditional 
make a complete examination of every registrant. The 
moment the physician on the Local Board finds a mental 
or physical defect placing the registrant within the 
standards of unconditional rejection the physician on the 
Local Board shall indicate this on Form 1010, section 
282, page 156, after ''physically deficient and not physi-^ t ^ calexam - 
cally qualified for military service by reason of" — in the 
space following write the disquahfying defect. 

In all other cases the Local Board shall make a com- 
plete examination of registrants ; and when the physician 
on the Local Board finds a defect which does not come 
within the standards of unconditional rejection, but 
does take the registrant out of the class, within the 
standards of unconditional acceptance, he shall proceed 
to make a complete examination and will then refer the 
registrant to the Medical Advisory Board, reporting the 
result of the complete examination, including a report 
of the defect or defects, on Form 1010. (Sec. 282, 
p. 156.) 

Registrants can not be declared physically qualified for Accept a net 

° •/-!-<• general service 

general military service (see Form 1010, section 282, p. only after com- 

v ., t , . -ii ill P lete examina- 

156) until the complete examination has been made by tnetion. 
physician on the Local Board, with the finding that the 
candidate comes in every instance within the standards 
of unconditional acceptance with or without remediable 
defect. Then it is so noted and recorded on Form 1010, 
section 282, page 156, and if there is a remediable defect, 
this is also recorded after " physically qualified for general 
military service." (C. S. S. R. No. 3, Jan. 28, 1918.) 

For Medical Advisory Boards. 

This Manual contains the new and more definite 
regulations for the physical examination of regis- 
trants for the guidance of the Medical Advisory 
Boards. 

The object of these regulations is to insure greater effi- 
ciency in the Selective Service. The members of Medical 
Advisory Boards should consider the regulations as a guide to 
their discretion. Therefore the regulations are not to be con- 
strued too arbitrarily. The object of the regulations is to 
procure men who are physically fit, or who can be made so, 



10 

for the rigors of field service, and the determination of this 
question is left to the judgment and discretion of Local 
and District Boards as advised by local examining physi- 
cians and by the Medical Advisory Boards. 

There should be cooperation between the Local Boards 
and the Advisory Boards. Cooperation may be made 
practicable through consultations and conferences between 
the Local Boards and Advisory Boards when this is 
possible. The majority of the Advisory Boards will have 
the opportunity to be in close touch with the Local 
Boards of their jurisdiction. In some large advisory dis- 
tricts the opportunity for frequent conference and con- 
sultation may be infrequent and difficult. However, 
through conferences between the Medical Aide to the 
Governor, the Chairman and the Secretary of the Local 
Boards, and of the Advisory Boards, ways and means for 
cooperation may be found with the object of securing 
greater efficiency in the physical examination of regis- 
trants. 

A Medical Advisory Board which has a full personnel of 
qualified specialists will be able to make a thorough 
examination. The number of members is not limited, 
and additional members of Advisory Boards may be nomi- 
nated at any time, through the Medical Aide, by the 
Governor for appointment by the President. (See sec. 
29, S. S. E.) 

The personnel of the Advisory Board should be kept at 
all times as full as efficiency demands. Members of the 
Advisory Boards who hold commissions in the Medical 
Reserve Corps, when assigned by the Surgeon General 
to active duty, automatically cease to be members of the 
Advisory Boards. Places on Advisory Boards thus made 
vacant may be filled as stated. 

The standard of efficiency of the Advisory Board should 
result in the rejection of all registrants referred to the 
Advisory Board for examination who are physically and 
mentally defective within the standards of unconditional 
rejection. This is very important as a measure of econ- 
omy and justice to the Government, the Army, and the 
registrant. 

On the other hand, it is just as important that the 
Medical Advisory Board should recognize and accept 
the registrants who are physically and mentally fit for 
general military service who are found to come within 



11 

the standards of unconditional acceptance with or without 
remediable defect. 

In those States and localities where it is impossible to 
organize an Advisory Board with a complete personnel 
of qualified specialists it is not expected that the Advisory 
Board will be able to carry out the complete directions 
for the physical examination of those registrants who 
require it. In this emergency the Medical Aide to the 
Governor, with the latter^s authorization, should make 
provision, if possible, for the registrant to be examined 
by competent specialists who may not be members of 
Advisory Boards, or recommend that such registrants be 
accepted by the Local Board and sent to the canton- 
ment for reexamination. The Advisory Board should 
examine registrants at the established headquarters of 
the Board, which by preference should be a general 
hospital. In certain emergencies the registrant may be 
sent elsewhere for special examination, such as taking a 
roentgenogram, withdrawing spinal fluid, eye and ear 
tests, etc. 

The Advisory Board is not required to make a com- 
plete examination of every registrant. At that point in 
the course of the examination when it is found that the 
registrant is physically or mentally unfit within the 
standards of unconditional rejection, he shall be re- 
jected. 

The place, order, and method of the general exami- 
nation by Advisory Boards should be the same as that 
advised for Local Boards. The procedure and methods 
of more exhaustive examination by Advisory Boards 
are included in this Manual. 

After the Advisory Board has completed the examina- 
tion of the registrant, the Chairman or a designated mem- 
ber of the Advisory Board shall certify the result in the 
proper space on Form 1010, and return the result in trip- 
licate to the Local Board through the mail or by mes- 
senger. 

It is the duty of the Advisory Board to advise the 
Local Board to classify all registrants examined by the 
Advisory Board as indicated in Form 1010. 

Those registrants who upon complete examination 
are found to come within the standards of unconditional 
acceptance with or without remedial defect, as indicated 
in the regulations for Local Boards, Part VIII, sections 



12 

182 to 188 inclusive, shall be reported as physically and 
mentally qualified for general military service. Group A. 

Those registrants who are found to come within the 
standards of unconditional acceptance for general mili- 
tary service, who have a remediable defect in the form 
of large hernia, trachoma, drug addiction, and other 
conditions described in this Manual, sections III to XXI, 
shall be accepted and designated by the Advisory Board 
by the diagnosis of the remediable defect, hernia, 
trachoma, drug addict, etc., followed by a circle in black 
ink. 

This designated group of registrants, (Group B or 
"def erred remediable group") when called, will be reme- 
died in cantonment base hospitals, reconstruction camps, 
or civic general hospitals as may be ordered by the Sur- 
geon General. It is recognized that registrants who suffer 
from trachoma and also drug addicts must be segre- 
gated in special camps for treatment. 

Those registrants found by the Advisory Boards 
physically and mentally unfit for general military service 
because they do not come within the standards of uncon- 
ditional acceptance, but who are found to be physically 
and mentally jit jor special or limited military service, 
shall be designated in Form 1010 by the diagnosis and 
occupation. This group (Group C) is clearly defined in 
this Manual, sections III to XXI. 

Those registrants found by the Advisory Boards to 
come within the standards of unconditional rejection 
(Group D) shall be so designated in Form 1010, followed 
by the diagnosis. 

II. PLACE, ORDER, AND METHOD OF EXAMINATION. 

Regulations for Local Board. (Section 183, S. S. R.) 

Method. The physical examination should take place in a large, 

well-lighted room. Question the registrant first about 
his physical condition, observe his mental characteristics 
and speech. 

Be on the lookout for malingering throughout the en- 
tire examination. Examine the scalp and face, nose, 
teeth, mouth, and fauces. Palpate the skull, then have 
the registrant strip of all his clothing, and make a gen- 
eral inspection of the skin over the entire body, of the 
conformation of the back, chest, and abdomen, of the 
region of the neck and buttocks, and of the upper and 
lower extremities. Inspect for the bulgings of hernia, 



13 

inspect the genitals, palpate the testicles, inspect the anus, 
tell the registrant to move all the joints of the extremi- 
ties and to bend the neck and body for observations on 
movements of the spine. 

Take the weight and height and chest measurements 
while the registrant is stripped of all his clothing. The 
chest measurements are taken on the level just above the 
nipple with the tape horizontal. 

During examination of the chest and of the eye and 
ear the registrant may put on his underdrawers, trou- 
sers, shoes, and stockings. 

Guard against the registrant becoming chilled. inSio y n. ical exam " 

The local physician can use his judgment as to the 
order of the physical examination. (C. S. S. R. No. 3, 
Jan. 28, 1918.) * 

These regulations may be followed .by the Medical 
Advisory Board. 

SPECIAL EXAMINATIONS AND STANDARDS FOR UNCONDI- 
TIONAL REJECTION, UNCONDITIONAL ACCEPTANCE, WITH 
OR WITHOUT REMEDIABLE DEFECTS, AND REFERENCE 
TO THE MEDICAL ADVISORY BOARDS. 

Regulations for the Local Board. (Section 184, S. S. R.) 

Remember that the Local Boards can accept or reject 
for general military service or refer the registrant to caf bSSS. 7 Lo ~ 
the Medical Advisory Board for further examination 
and classification. The Local Boards can not place the 
candidate in the class "physically qualified for special 
or limited military service, " except upon and in accord- 
ance with the finding and recommendation of the Medi- 
cal Advisory Board. 

m. MENTAL AND NERVOUS. 

Regulations for Local Board. (Section 184(a), S. S. R.) 

Reject insanity, epilepsy, idiots, imbeciles, and proven Rejection 
chronic alcoholism when the examination places the 
registrants within the standards of unconditional rejec- 
tion as defined below. 

Insanity. — All registrants who are committed or who Rejection. 
have been committed to a licensed institution for insane 
or licensed private institution, who bring proof from 
verified records of institution or State Boards. 

Epilepsy. — The registrant will be declared an epileptic Rejection. 
when verified histories establish the disease as of long 
duration and of the type of grand mal. 
40712°— 18 2 



14 

Rejection. Idiot. — A registrant so deeply defective in mind from 

birth or from early age that he is unable to guard him- 
self against common physical danger. 

Rejection. Imbecile. — A registrant so deeply defective in mind 

from birth or from early age as to be incapable of earn- 
ing a livelihood, but able to guard himself against com- 
mon physical danger. 

Rejection. Chronic alcoholism. — The registrant on examination 

must show suffused eyes, prominent superficial blood- 
vessels of nose and cheek, flabby, bloated face, red or pale 
purplish discoloration of mucous membrane of pharynx, 
and soft palate; muscular tremor in the protruded tongue 
and extended fingers, tremulous handwriting, emotional- 
ism, prevarication, suspicion, auditory and visual halluci- 
nations, persecutory ideas. 
toSti^nnot^f *^ ne history °F evidence that the registrant has been 
JSJd;ff dratfor frequently &n ^ grossly intoxicated is not of itself suffi- 
cient for a diagnosis of chronic alcoholism and rejection. 

Physical exam- Accept all registrants with apparent normal under- 

i •nation. * 

standing and whose speech can be understood and who 
have no definite signs of organic disease of the brain, 
spinal cord, and peripheral nerves. 

Refer all other registrants to the Medical Advisory 
Board. 

Regulation for Medical Advisory Boards. 

Reject all registrants as physically deficient and not 
physically qualified for military service by reason of — 
(give diagnosis) when the verified history or examination 
indicates the presence of or previous history of mental 
disease, disabling psychoneuroses, or organic diseases of 
the brain, spinal cord and peripheral nerves. No case 
of nervous or mental disease should be accepted for lim- 
ited or special service. Reject all of this class [except 
drug addicts], who are not believed to be capable of per- 
forming general military service. 

INSANITY. 

Reject. ^ registrant shall be rejected when there is a verified 

history of a mental disease that required hospital treat- 
ment or observation even when at the examination by 
the Medical Advisory Board the registrant is apparently 
mentally normal. The circumstances should, however, 
be inquired into with great care. 

The following are the most important clinical forms 
of insanity: 



15 

Paresis (general paralysis). — The diagnosis of paresis Re) 6 *- 
may be made when at the examination of the registrant 
a majority of the following signs and symptoms are 
demonstrated: Argyll-Robertson pupil or pupils, facial 
tremor, speech defect in test phrases, and in the slurring 
and distortion of words in conversation, writing defects 
consisting of omissions and the distortion of words. Apa- 
thetic or depressed or euphoric mood; these registrants 
may show memory loss, discrepancies in relating facts 
of life; the knee jerks may be plus, minus, or normal. 
Doubtful cases to be verified by Wasserman test of 
blood and examination of cerebrospinal fluid. If means 
of withdrawal of the cerebro-spinal fluid are not readily 
available, the registrant shall be accepted when there 
are no objective findings. 

Dementia precox. — Look for indifference, apathy, with- Reject, 
drawal from environment, ideas of reference and perse- 
cution, feelings of the mind being tampered with, of 
thoughts being controlled by hypnotic, spiritualistic, or 
other mysterious agencies, hallucinations of hearing, 
bodily hallucinations, frequently of electrical or sexual 
character; meaningless smiles; in general, inappropriate 
emotional reaction and a lack of connectedness in con- 
versation. There may be sudden einotional or motor 
outbursts. Get history of family life and of school, vo- 
cational, and personal career. 

Manic-depressive insanity. — Look for mild depression Reject* 
with or without feeling or inadequacy or mild manic 
states with exhilaration, talkativeness, and overactivity. 

Psychoneuroses. — Registrants who have been actu- Reject, 
ally and continuously incapacitated for a period of six 
months prior to May 18, 1917, from symptoms of hysteria, 
neurasthenia, psychasthenia, constitutional psychopathic 
state, etc., should be rejected. 

Others, although presenting hysterical stigmata or Accept, 
even hysterical paralysis, should be accepted. 

Epilepsy. — The registrant will be considered an epilep- 
tic when a history verified by physicians, scars of tongue, 
face, and head, and possibly characteristic voice, establish 
the disease as of long duration and of the type of grand 
mal. 

TREMORS, CHOREAS, AND TICS. 

Tremors do not disqualify by themselves. Chronic 
essential choreas should disqualify. Tics, or spasms of 



groups of muscles, should be considered in relation to the 
disability they occasion. Decision in these disorders in 
the discretion of the medical advisory board. 

ORGANIC DISEASES OF THE BRAIN, SPINAL CORD, AND 
PERIPHERAL NERVES. 

Kejeot. Registrants shall be rejected when the examination 

reveals definite signs and evidences of organic nervous 
disease — except that registrants in whom the history 
suggests an organic disease of the nervous system, and 
who may have certain after effects, shall be accepted as 
physically qualified for military service, provided (a) the 
disease is no longer operative and is not likely to recur, 
and (b) the effect left by the disease will not prevent a 
satisfactory fulfillment of general military duties. Ex- 
amples: Paralysis of a few unimportant muscles follow- 
ing poliomyelitis, slight unilateral hypertonicity as a 
result of infantile hemiplegia in a man now robust, and 
various traumatic conditions. A history of hemiplegia 
occurring after infancy should always be a cause of rejec- 
tion, even if no symptoms remain. 

When the medical advisory board is in any doubt as 
to the diagnosis of paresis or tabes or cerebro-spinal 
syphilis the usual test of the blood and the cerebro- 
spinal fluid may be made. When the spinal fluid is 
Wassermann positive, and there is an increase of the 
cellular count and globulin content the registrant shall 
be rejected, because all cases of proven syphilis of the 
central nervous system rejects the registrant from all 
military service. If means of withdrawal of cerebro- 
spinal fluid are not readily available, the registrants 
should be accepted. 

The following organic nervous diseases are often over- 
looked in the early stages: 

Tabes (or locomotor ataxia). — The diagnosis of this dis- 
ease may be made when, at the examination of the regis- 
trant, several of the following signs and symptoms are 
present: Argyll-Robertson pupil or pupils; absent knee 
jerk; Romberg symptom, ataxia of hands or legs (espe- 
cially with closed eyes), hypotonia, anesthetic areas of 
skin; the history is usually that of slow progression, of 
failing sexual power, and pain in the legs and back, often 
described as rheumatism. 

Cerebro-spinal syphilis. — The prominent diagnostic signs 
and symptoms are headache, pains in spine, pain referred 



17 

to distant regions through the involved cerebral and 
spinal nerves, varying deep and superficial reflexes, 
pupillary changes, ptosis and ocular palsies, facial weak- 
ness; mental state normal, dull, or apathetic. Look for 
comparative motor weakness of one side. A blood or 
spinal fluid Wasserman test may be necessary to make a 
definite diagnosis. 

Multiple sclerosis. — The diagnosis of this disease rests 
upon the following signs and symptoms: Intention 
tremor, nystagmus, absent abdominal reflexes, increased 
tendon reflexes, and scanning speech; in cases of this 
kind the history obtained is not characteristic, but some- 
times there may be a history of urinary disturbances. 

Muscular atrophies and dystrophies. — Progressive mus- 
cular atrophies and dystrophies shall be considered organic 
diseases of the nervous system and disqualify. The signs 
and symptoms are : Atrophies of the small muscles of the 
hand and in the muscles of the shoulder, with fibrillary 
twitchings. 

The history rarely furnishes reliable data, although ref- 
erence may be made to awkwardness. There is no his- 
tory of pain. 

DRUG ADDICTION. 

Registrants with history or symptoms of drug Accept. 
addiction, if otherwise mentally and physically fit 
for military service, shall be accepted for general 
military service in the deferred remediable group 
(Group B) and be so indicated by the Medical Ad- 
visory Board. 

CHRONIC ALCOHOLISM. 

The registrant who shows the majority of the symptoms 
mentioned in reference to chronic alcoholism in regula- 
tions for the Local Board shall be rejected. 

IV. SKIN. 

Regulations for the Local Board. (Section 184(b), S. S. R c ) 

Reject registrants who have long-existing skin diseases Rejection. 
which are so severe or so disfiguring as to be perma- 
nently incapacitating, or so disgusting or so disfiguring 
as to render the sufferers from them unsuitable for 
common social intercourse, or long-existing ulcers so 
severe or so extensive as to be permanently incapacitat- 
ing. 



18 



Acceptance. Refer remediable ulcers to the Medical Advisory Board. 
Accept registrants who have skin diseases which run 
an acute or temporary course, or are trivial in character, 
or do not interfere with the general health, or are not 
incapacitating. Among the common skin conditions 
coming in this category are: Acne, Anomalies of Pig- 
mentation, Scars, Condylomata, Diseases produced by 
pus infection, Eczemas which have not been of long du- 
ration, all forms of Naevi not producing great disfig- 
urement or deformity, all forms of Pediculosis, Scabies, 
Psoriasis, all forms of Ringworm, Warts, Callosities. 

Refer all other cases of skin diseases to the Medical 
Advisory Board. 

Diseases of Registrants with infectious, syphilitic, and parasitic 

temporary. . ■ 

character to be diseases of the skin of temporary character, or with other 
acute skin diseases, should be advised to accept treat- 
ment immediately, pending receipt of orders to report 
for duty. 
Acceptance. Accept all registrants with syphilitic lesions of the 
skin. 



Reject. 



Accept. 



Regulations for the Medical Advisory Board. 

Registrants suffering with the following diseases of the 
skin shall be rejected as physically deficient and not 
physically qualified for military service by reason of — 

Actinomycosis. 

Dermatitis herpetiformis of long duration. 

Epidermolysis bullosa. 

Forms of Universal Dermatitis of long duration. 

Glanders. 

Idiopathic Multiple Hemorrhagic Sarcoma of Skin. 

Mycosis fungoides. 

Pemphigus chronicus of long duration. 

Pemphigus foliaceous. 

Pemphigus vegetans. 
When the Medical Advisory Board is unable to make 
the correct diagnosis of one of the above diseases of the 
skin they may accept the registrant unless the skin 
lesion comes within the standard of unconditional 
rejection as defined in the Regulations to the Local 
Board. If not use their own judgment. 

Registrants with single or multiple lesions of the skin 
of a nonmalignant character which, in the judgment 
of the Medical Advisory Board, are remediable by treat- 
ment shall be accepted for general military service. 



19 



Registrants with large remediable ulcers shall be ao Accept, 
cepted for general military service in the deferred re- 
mediable group. (Group B.) 

Registrants with a lesion of the skin distinctly malig- Accept, 
nant, apparently curable, shall be accepted for general 
military service and placed in the deferred remediable 
group. (Group B.) 

Registrants who bring authentic proof that they have Acce v t - 
been operated upon for a malignant tumor of the skin, 
and who at the examination show no evidence of re- 
currence, shall be accepted for general military service 
when in the opinion of the Medical Advisory Board there 
is no great likelihood of recurrence. 

Registrants with a definite cancer of the lower lip or 
with a history verified by data that they have had re- 
moved from the lower lip by operation or otherwise a 
cancer of the lower lip shall be accepted for general 
military service only when the glands of the neck have 
also been removed and the microscopic section (verified 
by two pathologists) show no evidence of metastasis, 
otherwise the registrant shall be rejected from all military 
service. 

Registrants with the signs and symptoms of, or the 
history of, a thrombo phlebitis of the upper and lower 
extremity, associated with a disease of the skin, shall be 
accepted or rejected according to the regulations given 
in Section XII. 

It is important to repeat here to the Medical Advisory 
Board that registrants with syphilitic diseases of the skin 
shall be accepted for general military service unless the 
deformity due to ulceration and destruction of tissue 
places the registrant within the standard of unqualified 
rejection as given in the Regulations for the Local 
Board. 

V. HEAD. 

Regulations for the Local Board. (Section 184 (c) S. S. R.) 

Accept registrants with depression in the skull or Acceptance. 
with any abnormalities of the bones of the skull unless 
they come within the standards of unconditional rejec- 
tion noted under (a) Mental and nervous. 

Refer all doubtful cases to the Medical Advisory 
Board. 



20 



A.0C*pt, 



Reject. 



Accept, 



Accept. 



Acceptance. 



Physical ex- 
amination. 

Kejection. 



Regulations for the Medical Advisory Board. 

Registrants who have had a decompression operation 
in the region of the skull beneath the temporal or occipital 
muscles and who at examination show no bulging or 
marked pulsation may be accepted for general military 
service, providing they come within the mental require- 
ments and providing the condition for which this opera- 
tion was done has ceased to exist. 

Registrants with a skull defect in an area of the skull 
other than those mentioned in the previous paragraph 
and larger than a 25-cent piece shall be rejected for 
general military service irrespective of bulging, pulsation, 
or the absence of mental symptoms. If the skull defect 
is smaller than a 25-cent piece and there is no bulging or 
pulsation they may be accepted for general military 
service, providing they come within the mental require- 
ments and provided the condition which caused this 
defect has ceased to exist. 

Registrants with abnormalities in size and shape of the 
skull or other irregularity in the bones of the skull shall 
be accepted for general military service, if otherwise they 
come within the standards of unconditional acceptance. 

VI. SPINE. 

Regulations for the Local Board. (Section 184 (d) S. S. R. 

Accept all registrants with a normal spine or with 
slight curvatures which do not interfere with function 
and weight-bearing power. 

Reject all registrants with signs and symptoms of un- 
doubted extensive disease of the vetebrae which totally 
incapacitate. The wearing of a plaster jacket does not 
of itself reject. 

Refer all other registrants and doubtful cases to the 
Medical Advisory Board. 

Regulations for Medical Advisory Board. 

Registrants presenting themselves to the Medical Ad- 
visory Board wearing plaster jackets must submit to the 
removal of this jacket in order to allow a complete- 
examination. 

This jacket should not be removed until there is pro- 
vision for its reapplication. 



21 

PROVEN TUBERCULOSIS OF ANY PORTION OF THE VERTE- 
BRAL COLUMN REJECTS. 

Reject. 

Registrants with definite signs of abscess or sinus and 
definite signs of fixation of the vertebral column shall be 
rejected on these signs only. 

Registrants with kyphosis, referred pain, and no sign 
of abscess and sinus shall be subjected to X-ray plate 
before a diagnosis of a destructive disease is definitely 

made. 

Nontuberculous diseases of the vertebral col- 
umn which have produced limitation of motion in 
any portion of the spinal column shall reject the 
registrant for military service. 

The degree of disability taken in reference to the 
registrant's present ability to work shall decide whether 
the registrant shall be accepted for limited service or 
rejected from all military service. 

The decision in this group shall rest upon the examina- 
tion including local and referred pain, muscle spasm, 
fixation of the vertebrae, and the reading of the X-ray 
plate. 

FRACTURES OF THE VERTEBRAE. 

Registrants with fractures of the coccyx shall be ac- 
cepted for general military service. 

Fractures of the sacrum and pelvic bone, when the 
diagnosis is confirmed by an X-ray plate, shall reject the 
regFstrant from both general and limited military service. 

FRACTURES OF CERVICAL, DORSAL, AND LUMBAR VERTEBRAE . 

Registrants with a history of a fracture of the spine, 
even with slight kyphosis, without marked symptoms 
and who, on examination, show no loss of function or 
weight-bearing power shall be accepted for general 
military service. 

All other cases of fracture of the vertebrae in which 
the diagnosis is confirmed by the X ray shall be rejected Re J ect - 
for all military service. 

SCOLIOSIS (lateral curvature of the spine). 

If this lateral deviation from normal mid line is 2 
inches or less, the registrant shall be accepted for general Acce P t - 
military service. 



22 

If the lateral deviation from normal mid line is more 
than 2 inches and less then 3 inches, the registrant shall 
Accept. ^ accepted for limited military service. 

If the lateral deviation from normal mid line is more 
Reject. than 3 inches, the registrant shall be rejected from all 

military service. 

SACRO-ILIAO AND LUMBOSACRAL JOINTS. 

Registrants who claim to have suffered from symptoms 

of or to have been treated for affections of these joints 

and who, at examination, show no objective signs or 

Accept. symptoms shall be accepted for general military service. 

Registrants who, on examination, show objective signs 
and symptoms of affections of these joints shall be kept 
under observation for a reasonable length of time (three 
months) . 

If at the expiration of this time the examination re- 
Aecept. veals no objective symptoms or signs, they shall be ac- 

cepted for general military service. 

If there are any objective signs or symptoms, the regis- 

Reject trant shall be rejected for general military service or 

accepted for limited military service, according to the 

degree of disability taken in reference to the registrant's 

present ability to work. 

The diagnosis of affections of the sacro-iliac and lumbo- 
sacral joints shall rest upon the demonstration of referred 
pain to the lower extremities, of muscle spasm, of pos- 
tural deformities, and limited motion of the spine and 
lower extremities, confirmed by the radiograph combined 
with the interpretation thereof. 

A sinus or abscess in the region between the coccyx and 
anus shall not be interpreted as a sinus in relation to 
disease of the vertebrae. When X ray shows no disease 
of bone, these abscesses and sinuses may be due to the em- 
bryonic remains of the pilo-nidai sinus. Registrants 
Accept with such conditions shall be accepted for general mili- 

tary service (Group A) . 

Recent contusions or sprains of the spinal column shall 
be looked upon as temporary defects. After a reason- 
able time the registrant shall be reexamined. 

SCAPULA. 

Registrants presenting prominent scapulae when due 
Accept. £ other cause than paralysis shall be accepted for general 

military service. 



23 

Registrants presenting prominent scapulaB due to Accept, groapa, 
paralysis shall be accepted for special or limited military 
service. 

VH. EARS. TESTS FOR HEARING AND MALINGERING. 



Rejection. 



Test of hearing. 



Regulations for the Local Board. (Section 184 (e) S. S. R.) 

Reject when it can be absolutely proven that the 
registrant is totally deaf in both ears. 

Accept when the hearing in both ears is above the Acceptance. 
standard of 10/20. 

Refer to the Medical Advisory Board when the hear- 
ing is below the standard of 10/20 in one or both ears, 
or there is complete deafness in one ear. 

To determine hearing, the hearing of the examiner 
should be normal. 

Place the registrant facing away from the assistant, 
who is twenty feet distant, and direct him to repeat 
promptly the words spoken by the assistant. If the 
registrant can not hear the words at twenty feet, the 
assistant should approach foot by foot, using the same 
voice, until the words are repeated correctly. Examine 
each ear separately, closing the other ear by pressing the 
tragus firmly against the meatus; the examiner faces in 
the same direction as the registrant and closes one of his 
own ears in the same way as a control. The assistant 
speaks in a low conversational voice (not a whisper) just 
plainly audible to the examiner, and should use numerals, 
names of places, or other words or sentences until the 
condition of the applicant's hearing is evident. The 
acuity of hearing is expressed in a fraction the numerator 
of which is the distance in feet at which the words are 
heard by the registrant and the denominator the distance 
in feet at which the words are heard by the normal ear; 
thus 20/20 records normal hearing, 10/20 imperfect hear- 
ing, etc. If any doubt as to the correctness of the answer 
is given, the registrant should be blindfolded and a watch 
should be used, care being taken that the individual does 
not know the distance from the ear at which it is being 
held. The watch used should be one whose ticking 
strength has been tested by trial on a normal ear. 

Accept all registrants whose hearing is above the 
standard of 10/20 in both ears and who have no chronic 
discharge from the middle ear. 



Acceptance. 



24 

iJul£ M exam " R efer to the Medical Advisory Board all registrants 
with chronic discharge from the middle ear and all 
doubtful cases. 

Regulations for the Medical Advisory Board. 

Before making any decision in regard to conditions of 
the external ear and external auditory canal the test 
for the acuity of hearing must be made. 

Registrants can not be accepted for general military 
service unless the hearing in loth ears is 10/20 or above. 
This is the regulation for the Local Board and there must 
be no deviation from it. Before making this test clean 
the ear of dirt and wax so that the membrana tympani is 
clearly visible. 

Accept Accept registrants with the loss of one or both external 

ears or with any deformity of one or both ears or with 
any lesion of the skin of one or both ears whose hearing 
is within the standard of unconditional acceptance. 

Accept. Accept registrants with any lesion of the external 

auditory canal except a definite malignant tumor when 
the hearing in both ears is within the standard of accept- 
ance. 

INFECTIONS OF THE MIDHLE EAR. 

Registrants with signs and symptoms of a recent 
middle ear infection with or without perforation should 
be held as temporary defects and given a reasonable 
time to allow the lesion to be treated or healed before 
they are reexamined. 

Reject. Registrants with perforations of the membrana tym- 

pani and a chronic discharge from the middle ear when 
this is clearly determined by otoscopic inspection shall be 
rejected for all military service. 

Accept. Registrants in whom the otoscopic examination de- 

tects a perforation of the membrana tympani but detects 
no discharge shall be accepted for general military 
service. 

The Medical Advisory Board is urged in cases 
of this kind to be certain that there is no dis- 
charge from the middle ear before accepting the 

REGISTRANT FOR GENERAL MILITARY SERVICE. In CASES 
OF DOUBT THE REGISTRANT CAN BE GRANTED A REA- 
SONABLE DELAY BEFORE COMPLETING THE EXAMINA- 
TION. See section 187, S. S. R., Temporary Defects. 
Registrants whose hearing in one or both ears is less 
than 10/20 but more than S/20 shall be accepted for 



25 

special and limited military service providing the oto- 
scopic examination reveals no perforation of the mem- 
brana tympani with discharge from the middle ear. 

Reject registrants whose hearing in one or both ears 
is less than 5/20 from any military service. 

TESTS FOR MALINGERING IN HEARING. 

Cases of this character have been chiefly magnifications 
of slight imperfections on one side, together with com- 
plaint of past troubles. Exaggeration of defects in hear- 
ing extends to declarations of total deafness on one side. 
The following tests are recommended: 

1. In testing malingering the suspect should be placed 
in the center of the room free from all obstructions. His 
eyes should be securely and completely blindfolded. 

2. An accurate notation of the deaf ear should be made 
and a critical examination of the auditory canal and 
membrana tympani. Where possible the patulency of 
the eustachian tubes should be determined. 

3. An accurate testing out of the normal ear should 
first be established. Care should be exercised not to 
allow the suspect to hear figures or other signs as to re- 
sult of examination. 

4. In making these examinations, the observer should 
have a skilled assistant, and all communications between 
them should be in a low, whispered voice. 

5. The assistant should stand at the back of the pa- 
tient and should at the direction of the examiner obstruct 
the ears of the suspect as directed by pressing the tragus 
firmly into the auditory meatus. 

6. If the suspect gives markedly conflicting statements 
when the normal ear is tightly plugged as to the distance 
at which he hears the voice or accumeter, it is fair to 
assume he is a malingerer. 

7. The simplest and most available test for malingering 
is an ordinary binaural stethescope. One ear piece, the 
one to be applied to the normal ear, is packed tightly 
with a wad of absorbent cotton and the ear pieces are 
placed in the suspect's ears. The examiner speaks in a 
soft tone or counts into the bell-shaped chest portion of 
the stethescope, and the suspect is told to repeat what he 
hears. The tubes are removed from the ears, and the 
assistant is told to stop the normal ear. The same 
words or numerals are again repeated. The suspect will 
now claim failure to hear the words or numerals which he 



26 

had previously heard through the tube with the ear stated 
to be deaf. 

8. Erhard's test is another simple method for maling- 
erers which requires no special apparatus. If the 
external auditory canal of a normal ear is tightly packed 
with absorbent cotton, it will still conduct sound waves to 
a limited degree, a loud ticking watch even under these 
circumstances being heard about one or two meters. The 
suspect has his ear which is stated to be deaf stopped 
and then the test is made with the hearing of the normal 
ear, the suspect being told to count the click of the 
watch. The suspect's normal hearing ear is then stopped 
and the testing is made with the supposed deaf ear. 
Under this test, if he claims failure to hear the watch 
under 1 meter, you may be certain he is malingering. 

9. The Chiman-Moos test is made with the C2 tuning 
fork. The vibrating tuning fork is held at equal dis- 
tances from each ear. The suspect will claim that he 
hears it better in the normal ear. The vibrating tuning 
fork is then placed on the vertex of the skull. The 
suspect hearing it equally well in both ears will at first 
hesitate, and then state he hears it better in the normal 
ear. In diseases of the conducting apparatus, as is well 
known, he should hear it better in the diseased ear. If, 
now the external meatus of the normal ear is tightly 
closed and the vibrating tuning fork is placed upon the 
vertex of the skull, the individual with the diseased ear 
will state he hears it better in the normal closed ear; 
or, it may be impossible for him to decide in which ear 
he perceives the tone better. The suspect, with the 
normal ear tightly obstructed, will state that he does not 
perceive the sound of the fork when thus placed on the 
vertex of skull. 



Vin. EYES. TESTS FOR VISION AND MALINGERING. 

Regulations for the Local Board. (Section 184 (f) S. S. R.) 
Rejection. Reject all registrants with the absence of one eye and 

when there is no doubt they are totally blind in both 
eyes. 
Acceptance. Accept all registrants with vision 20/100 in one eye 
and 20/40 in the other without glasses or 20/100 in each 
eye without glasses if correctable with glasses to 20/40 
in either eye. When the physician on the Local Board 
is not supplied with test glasses and the registrant has 
not glasses refer to the Medical Advisory Board. 



27 

Accept all registrants who come within or exceed the 
above visual requirements though they may have the fol- 
lowing slight defects: 

Slight adhesions of the lids to the eyeball. 

Small pterygium. 

Slight eversion of the lids. 

Ptosis, when not interfering with vision. 

Strabismus, if vision up to standard. 

Iridectomy, or other operation is in itself not a cause 
for rejection if condition for which it was performed is 
relieved. 

Color-blindness is not a cause for rejection. 

Refer to the Medical Advisory Board all other cases. 

Vision. — To determine the acuity of vision, place the 
person under examination with back to window at a dis- 
tance of 20 feet from the test types. Examine each eye 
separately, without glasses, covering the other eye 
with a card (not with the hand). The applicant is di- 
rected to read the test types from the top of the chart 
down as far as he can see, and his acuity of vision re- 
corded for each eye, with the distance of 20 feet as the 
numerator of a fraction and the size of the type of the 
lowest line he can read correctly as the denominator. If 
he reads the 20-feet type correctly, his vision is normal 
and recorded 20/20 ; if he does not read below the 30-f eet 
type, the vision is imperfect and recorded 20/30; if he 
reads the 15-feet type, the vision is unusually acute and 
recorded 20/15, etc. 

Regulations for Medical Advisory Board. 

All registrants referred to the Medical Advisory Board 
with eye defects must be examined if possible by a thor- 
oughly qualified ophthalmologist selected by the board. 

The lids of every registrant must be everted for the 
purpose of determining the presence or absence of 
Trachoma. 

Examine condition of pupils, their size, shape, and 
motor reaction to light and to accommodation. Abnor- 
malities should be considered with reference to disease 
of the central nervous system as well as of the eyes. 

Especial attention should be paid to all those whose 
vision is below the required standard. When no cause 
for the defective sight can be determined by objective 
methods, including an ophthalmoscopic examination, 
they should be tested for malingering. 



Test of vision. 



28 
accept. i Accept for general military service. 

Visual requirements: Vision 20/100 in one eye and 
20/40 in the other, without glasses, or 20/100 in each eye 
without glasses, if correctable with glasses to 20/40 in 
either eye. 

Accept 2. Accept for special or limited military service. 

Visual requirements: Vision 20/200 in one eye and 
20/40 in the other (either right or left) without glasses, 
or, 20/200 in each eye without glasses if correctable with 
glasses to 20/40 in either eye. 

Accept Slight defects, acceptable as M for general mili- 

tary service. 

Slight nystagmus. 

Slight conjunctivitis. 

Registrants with chronic conjunctivitis in dis- 
trict WHERE TRACHOMA IS COMMON SHOULD BE MOST 
CAREFULLY STUDIED. If THE DIAGNOSIS OF TRACHOMA 
CAN NOT BE EXCLUDED, THE REGISTRANT SHALL BE 
ACCEPTED FOR GENERAL MILITARY SERVICE IN THE 
DEFERRED REMEDIAL GROUP (Group B). 

Accept Registrants with trachoma otherwise physically 

and mentally fit, with vision up to the standard 
for general military service shall be accepted for 
general military service in the deferred remediable 
group. (Group B.) 
Accept. Registrants suffering with the following remediable de- 

fects otherwise physically and mentally fit, and whose 
vision is within the standards of acceptance shall be 
accepted for general military service in the deferred 
remediable group (Group B) : 

Inversion of the eyelids. 

Marked eversion of the eyelids 

Ptosis, interfering with vision. 

Trichiasis. 

Epiphora. 

Chronic blepharitis. 

Pterygium (extensive). 

Chronic dacryocystitis. 

Blepharosp asm . 

Superficial corneal ulcer. 

Acute inflammatory diseases of globe. 



29 

Unfit for military service. The following are causes 
for unconditional rejection: 

All registrants whose vision is below 20/200 in each eye, Re J ect - 
without glasses. 

All registrants whose vision, without glasses, is 20/200 
and not correctable, with glasses, to 20/40 in either eye. 

Disfiguring cicatrices. 

Lagophthalmos (inability to close the lids). 

Pronounced exophthalmos (Pathologic). 

Chronic keratitis. 

Chronic recurrent inflammatory diseases of the globe. 

Deep ulcers of the cornea. 

Opacities of the lens, or its capsule, sufficient to reduce 
the vision below the standard, and progressive cataract of 
any degree. 

Any organic disease of the retina, choroid, or optio 
nerve. 

Detachment of the retina. 

Marked nystagmus. 

Loss or disorganization of either eye. 

Glaucoma. 

All eye signs associated with toxic goiter. 

Malignant tumors of the lids or globe. If operation has 
been performed for malignant growth and proof fur- 
nished, it is cause for rejection. 

Diplopia, if associated with paralysis of the extrinsic 
ocular muscles. 

VISUAL TESTS FOR THE DETECTION OF MALINGERERS. 

Malingerers may feign inability to open their eyes, total 
loss of vision in one or both eyes, or impaired vision in 
one or both eyes. Occasionally an inflammation in the 
eyes will be produced by putting sand or other irritating 
substance under the lids. 

Malingerers who wish to evade military service by 
feigning impairment of vision may be divided into two 
classes as follows : 

A. Those who claim total loss of vision in one eye 

B. Those who claim partial loss of vision in one or both 
eyes. 

Either group may have a normal acuity of vision or 
may exaggerate a defect actually present. 

In testing for malingering the medical examiner should 
bear in mind that detection is more likely to result when 

40712°— 18 3 



30 

the man is allowed to believe that his case is regarded 
from the first to be genuine and that his story is not 
discredited. There is something indefinable in the bear- 
ing of the malingerer which experience alone can detect. 
He may be self-assertive and overconfident; he may be 
hesitating or evasive. Careful observation should be 
made of his conduct and every movement noted. The 
nature of the man's answer should be taken into account 
and considered in the light of the kind of reply that is 
given when a genuine refraction case is being dealt with. 
The following equipment is necessary: 

1. Trial frame; blank; spherical lenses, +16, +3, 
-hO.25, -3, -2, -1, -0.25. 

2. Two prisms, one 6°, one 10°. 

3. Ophthalmoscope (electric battery in handle). 

4. Condensing lens. 

5. Loupe. 

6. Red and green letters on glass; (a) letters varying 
in size; (b) spectacle frame containing red and green 
glasses. 

7. Special test cards, one a duplicate, with letters re- 
versed to use with a mirror. 

8. Special illiterate test cards. 

9. Mirror, large enough to reflect test card. 

10. One stereoscope with special cards. 

11. Retinoscope (electric with battery in handle). 

12. Ruler, about 1| inches wide. 

METHODS OF EXAMINATION. 

Class A. Total loss of vision in one eye. 

(a) A 6° prism base downward is placed before the ad- 
mittedly sound eye, while the man looks at a distant fight 
or candle. If he sees two candles, binocular vision is 
proved. The examiner may vary the test by placing 
the prism before the " blind" eye, either base up or base 
down. 

^6) A prism of 10° with base outward is placed before 
the " blind" eye. If there is any sight in this eye, double 
vision will be produced and the eye will be seen to move 
inward to correct it and fuse the two images. 

(c) The alleged " blind" «ye is covered. A prism of 
10° with the apex up is placed before the seeing eye in 
such a position that its edge lies horizontally across the 
center of the pupil. This produces monocular diplopia. 



31 

The prism is then moved upward so as to be completely 
in front of the good eye and at the same time the u blind" 
eye uncovered. If diplopia is produced or admitted, 
there is sight in the " blind" eye. 

(d) Test with colored glasses and letters: This con- 
sists in directing the individual to read a row of red and 
green letters through a red and green glass. The red 
letters will be invisible to the eye that has the green glass, 
and vice versa, but if all the letters are correctly read irre- 
spective of their color, there must be sight in the "blind " 
eye. The proper illumination back of the chart must be 
observed. 

(e) Test with trial glasses: A high plus glass is placed 
before the good eye and a low plus or minus before the 
"blind" eye. If the dista»t type is read, the vision in 
the "blind" eye is good. 

(/) The stereoscopic test: This may be made with or- 
dinary stereoscope, the printed matter so arranged that 
certain portions of it are not present before one of the 
eyes. 

(g) The bar test: Interpose a ruler about 1^ inches 
wide vertically midway between the two eyes at about 4 
to 5 inches distance, direct the man to read from a printed 
page with lines at least 4 inches long. If able to read the 
lines, binocular vision exists. 

Qi) The action of the pupil must be carefully tested, 
there usually being no movement to light stimulation 
when the eye is blind. If the examiner is not satisfied, 
the following examination should be made: 

Oblique examination. — A careful examination of the 
cornea should be made with the aid of a condensing lens 
and a loupe. 

Ophthalmoscopic examination. — A searching examina- 
tion with the ophthalmoscope should be made together 
with an estimation of the refractive error. The pupil 
should be dilated if necessary. 

Class B. Partial loss of vision in one or botn eyes. 

The most common manitesfation of malingering takes 
the form of a statement that one eye is imperfect. Men 
pleading this disability may be divided into two classes: 

(a) Those who pretend to have a visual defect. 

(6) Those who are aware they have a visual defect and 
exaggerate its effect. 



32 

No hard and fast tests can be prescribed for the detec- 
tion of these cases. Much depends on the alertness and 
ingenuity of the medical examiner. 

The tests with prisms are not applicable here, for there 
is not pretended blindness in one eye, but simply an 
alleged diminution of visual acuity. 

METHODS OF EXAMINATION. 

(a) If a room 30 or 40 feet long can be ob tamed for 
testing vision, place the registrant suspected of malinger- 
ing at 30 to 35 feet from the test chart. Direct him to 
read the letters and note the result. He should then be 
brought up to 20 feet from the card and retested. If he 
reads the same line he is malingering. 

(&) Mirror tests with special test cards. (See equip- 
ment No. 7.) 

Test cards are used which are identical, one having the 
letters reversed. The registrant is directed to read the 
letters on the chart across the room, and then in a mirror 
beside it, which reflects reverse letters that are placed 
over his head. The letters seen in the mirror are located 
double the distance of the direct letters from the man 
being examined. The malingerer is apt to read in the 
mirror the line which he read on the first card, showing 
that his vision is twice as good as he pretends. 

In order to obviate the use of test letters in the mirror 
test, various common objects approximating the size of 
the 20/40 and 20/30 letters may be used by asking the 
registrant to differentiate between a dime and penny, a 
cigarette and pencil, a pen and pencil, the number of 
spots on playing cards, or between the different aces, 
held on either side of his head and reflected in the mirror 
at 20 feet distance. 

Trial frame test: Place a trial frame upon the man's 
face and put before the sound eye a high convex lens 
( + 16D), and before the "blind" eye a plane or weak 
lens (0.25) which will not interfere with vision. If 
letters placed at distance of 20 feet are read, the fraud 
is at once exposed. 

(c) Oblique examination with condensing lens and 
loupe to determine corneal or lenticular opacities. 

(d) Ophthalmoscopic examination : It is probable that 
the malingerer will resist the ophthalmoscopic examina- 
tion by frequent winking or rolling of the eyes. In this 



33 

event it is best to caution the man that a report of his 
vision must be made,, and then to postpone further 
examination until after the next few registrants have been 
examined. 

(e) Estimate the refractive error with the use of the . 
ophthalmoscope. If no error of marked degree exists 
and the media and fundi are normal, the relation between 
the alleged vision and the refractive condition furnished 
an important clue. If the error is about 4-4.00 or —2.00 
the visual acuity could be about 20/100, but when the 
defect can not be accounted for objectively, and the 
vision is brought from 20/100 to 20/50 or 20/30 by means 
of a low plus or minus glass, the man is malingering. 

(/) Retinoscopy: Look for corneal and ' lenticular 
opacities and estimate refractor errors. 

OCCUPATION. 

The man's occupation in civil life may have been such 
that it could not have been followed without more 
vision than he claims. 

In the absence of ocular defects, continuous and per- 
sistent blepharospasm, the use of colored glasses, eye 
shades, or eye bandages should be regarded with suspicion. 

DIPLOPIA. 

Cases of malingering are occasionally met with in 
which the men complain that they see double. These 
must be investigated with the application of the ordinary 
tests as if they were genuine, with every precaution 
taken to guard against a serious nervous lesion being 
overlooked. 

IX. MOUTH, NOSE, FAUCES, PHARYNX, LARYNX, TRACHEA, 

AND ESOPHAGUS. 

Regulations for the Local Board. (Section 184 (g) S. S. R.) 

Reject all irremediable deformities and diseases which Reject. 
interfere with mastication of ordinary food, and inter- 
fere with speech so the registrant can not be understood. 

Reject registrants who have a permanent gastrostomy Reject. 
or who are wearing a permanent tracheotomy tube. 

Accept all registrants who have not complete obstruc- 
tion to nasal breathing. 



34 



Accept. 



Accept all registrants with, nasal polypi, deviation of 
septum, enlarged tonsils and adenoids if obstruction to 
nasal breathing is not complete, and all remediable be- 
nign tumors. 

Refer all other cases and all doubtful cases to the 
Medical Advisory Board. 

Regulations for Medical Advisory Board. 

The regulation to the local board just given in regard 
to the mouth, nose, fauces, pharynx, larynx, trachea, 
and esophagus, and the regulation in regard to the 
diseases of the skin (see section IV) clearly describe 
ulcerating and deforming conditions which, if present 
to a certain degree, shall disqualify. 

TUBERCULOSIS. 

Tuberculosis of the mouth, nose, fauces^ pharynx, and 
larynx is rarely present without definite signs of tubercu- 
losis of the lungs. Therefore, when the registrant has 
no objective sign of tuberculosis of the lungs, the diagno- 
sis of tuberculosis of the mucous membrane of the cavities 
under consideration should not be made without the 
confirmation of the microscope either from a section of a 
piece removed, or the demonstration of the tubercle 
bacilli in material obtained from the surface of the 
diseased area. 

In some instances of chronic laryngitis, with marked 
ulceration, the diagnosis of tuberculosis can be made 
without the aid of a laboratory, but the sputa should 
be examined for tubercle baccilli in cases of this kind and 
a section need not be taken. 



Deferred 
animation. 



MALIGNANT DISEASE. 

In some cases of cancer of the mucous membrane of 
the areas under consideration, the diagnosis can be 
made by inspection. Registrant with such diseases shall 
be rejected. 

In some cases of carcinoma of the antrum and sarcoma 
in the region of the mouth and jaws, the diagnosis can 
be made by inspection with the aid of the X-ray. 

When the diagnosis of malignant disease can not be 

made by these ordinary methods, the examination of 

the registrant shall be temporarily deferred, section 1S7. 

S. S. R., and final examination and judgment deferred, 

giving the registrant a reasonable time to submit to the 



35 

appropriate treatment which is best for his relief, and at 
which treatment a correct and final diagnosis will be 
made. 

The excision of small pieces of tissue for miscroscopic 
study, simply to make a diagnosis and to determine 
whether a registrant has malignant disease or not, must 
not be done unless it can be done without any danger 
whatever to the registrant, and with his consent. 

Malignant diseases in these areas in ages under 31 are 
relatively infrequent. 

Registrants who bring authentic data of operations in Reject. 
these areas for malignant disease shall be rej ected unless 
there is a period of at least three years and examination 
shows no evidence of recurrence. 

These cases should be carefully studied because many 
benign tumors have been diagnosed malignant. Dentig- 
erous cyst, adamantine epithelioma, and giant cell 
sarcoma should not be classed as malignant. 

(ESOPHAGUS. 

When registrants complain of inability to swallow, the 
diagnosis of a stricture of the oesophagus as the cause 
of this complaint must be confirmed by the introduction 
of a tube, by an X-ray picture after the swallowing of Re ^ ect ^ 
a bismuth mixture, and when possible by the employ- 
ment of the cesophagoscope. Evidence of organic stric- 
ture of the oesophagus shall reject. When there is no Aooe ^" 
evidence of organic stricture of the oesophagus and all 
other examinations are negative as to an objective 
cause, the registrant shall be accepted. 

Before there can be any conclusion as to the accept- 
ance of the registrant for general military service it should 
be determined that he has the required number of teeth, 
vision, and hearing, within the standard of unconditional 
acceptance. 

NOSE. 

Benign growth of any kind, nasal polypi, hypertrophy Accept. 
of the mucous membrane, benign superficial ulcerations, 
deviation of the septum. 

ADENOIDS AND ENLARGED OK, INFECTED TONSILS, HARE 
LIP, RANULA, AND BENIGN TUMOR ON MOUTH. 

Nasal obstruction or discharge from the nose of these Accept, 
registrant shall not be considered a cause for rejection. 



36 

Before accepting any of the above remediable defects 
of registrant with obstruction to breathing or discharge 
from the anterior or posterior nares, an examination 
should be made for involvement of the sinuses with a 
purulent secretion (sinusitis). This examination shall 
consist of not only the usual inspection of the nose and 
throat, but the transillumination of the sinuses and two 
or more X-ray plates of them. The demonstration of 
chronic sinusitis places the registrant in the deferred 
remediable group; the demonstration of acute sin- 
usitis causes the registrant examination to be temporary, 
(sec. 187). Registrants shall be given a reasonable time 
for recovery and treatment and then reexamined. When 
the evidence of involvement of the sinuses has disap- 
peared, the registrant shall be accepted as physically 
qualified for general military service; when still pres- 
ent he shall be placed in deferred remediable group 
(Group B). 

LARYNX. 

Hoarseness and alteration of the voice should indicate 
an inspection of the larynx with larynxgoscope ; acute and 
chronic laryngitis do not disqualify. Syphilitic laryn- 
gitis only disqualifies when the ulceration is of such a 
degree that the registrant has permanently lost power 
of talking so that he is understood. Paralysis of one 
vocal cord due to operation does not disqualify. 
Accept. Aphonia, after an examination with negative result, 

should not disqualify, as it is usually hysterical or 
malingering. 

The registrant who presents benign tumors of the 
larynx shall be placed in the deferred remedial group 
(Group B). 

Physically qualified for special or limited military service. 

Registrants whose defects are not remediable, and 
within the standard of unconditional acceptance, and 
not of sufficient degree to come within the conditions of 
unconditional rejection, shall be placed in the group for 
special or limited military service. (Group C.) 

Defects which will place the registrant in this group 
(Group C) are ankylosis of the lower jaw, perforations of 
the hard palate, deformities interfering to a modified de- 
gree with mastication and speech. 



37 

X. NECK. 

Regulations for the Local Board. (Sec. 184= (h) S. S. R.) 

Reject fully developed exophthalmic goiter when there Re iect. 
is present thyroid enlargement, pulse rate above 120 and 
exophthalmos. 

Accept registrants with normal necks, moderate en- ^en- 
largement of the thyroid with no toxic symptoms. Ac- 
cept with a few palpable lymph glands with or without 
healed scars and no sinuses. 

Refer all other and doubtful cases to the Medical Ad- 
visory Board. 

Regulations for the Medical Advisory Board. 
EXOPHTHALMIC GOITER. 

Registrants with fully developed exophthalmic goiter Ee i ect > 
shall be rejected for any military service. The diag- 
nosis rests more, upon the toxic symptoms than upon 
the enlargement of the thyroid. These toxic symptoms 
are rapid pulse (tachycardia), pulsation of the vessels of 
the neck, high blood pressure, lymphocytosis, and certain 
eye signs, most prominent of which is exophthalmos of 
both eyes and tremor of the fingers. 

Registrants who claim to have been treated or operated ' R ^ 6Ct - 
upon for exophthalmic goiter and who still show toxic 
symptoms should be rejected. If, however, the registrant 
shows absolutely no evidence of toxic symptoms with or 
without the scar of an operation upon the thyroid he 
should be accepted for general military service, unless he 
can bring verified proofs of preexisting exophthalmic 
goitre from the physician or surgeon who treated him 
then he should be rejected. 

SIMPLE GOITER AND BENIGN THYROID TUMOR — NON- 
TOXIC TYPE. 

Registrants with symmetrical enlargement of the thy- 
roid (simple goiter) and asymmetrical enlargement of 
lobes or isthmus (benign thyroid tumors) should be ac- Accept. 
cepted for general military service if after careful exam- 
ination they show no evidence of toxic symptoms. 

When the enlargement of the thyroid is sufficiently 
great to prevent the wearing of the soldier's uniform, 
accept for general military service deferred remediable 
group (Group B) and diagnosis large goiter. 



38 

TOXIC TYPE. 

Registrants whose enlargement of the thyroid, corre- 
sponds to the previous group just described who on ex- 
amination show one or more of the toxic signs should 
be accepted, for general military service deferred remedi- 
able group (Group B) and diagnosis toxic goiter. 

Registrants who give a history of an operation for 
enlargement of the thyroid or any benign tumor of the 
thyroid and show a healed scar and who have on exami- 
nation no evidence of toxic symptoms shall be accepted 
for general military service. When, however, there is 
still present toxic symptoms, especially tachycardia, high 

blood pressure, and tremor, they should be rejected. 

• 

MYXOEDEMA, 

Reject. Registrants with definite signs of myxoedema, whether 

associated with goiter or not, should be rejected. The 
diagnosis should rest upon slow mental processes, loss of 
hair, and the accumulation of fat, especially above the 
belt. This condition is very rare in this country, even 
after operations for the thyroid gland. When there is 
any doubt as to the diagnosis of myxoedema, the regis- 
trant should be accepted for general military service. 

TUBERCULOUS GLANDS OF THE NECK. 

This condition of the lymph glands of the neck is not 
of itself a cause for rejection. 

Registrants with healed scars in the neck with a his- 
tory of suppurating glands shall be accepted for general 
military service even if there are still some small glands 
to be palpated. 

Registrants who give a history of removal of tubercu- 
lous glands of the neck and who show on examination a 
Accept. healed scar shall be accepted even if there are a few 

small glands to be palpated. 

Registrants with small palpable glands of the neck 
otherwise physically fit for general military service, 
shall be accepted. 

Registrants with a single sinus in the neck with a his- 
tory of suppuration as the cause of the sinus otherwise 
Accept. physically fit shall be accepted for general military 

service. 
Reject. Registrants with multiple sinuses of the neck of long 

duration should be rejected., 



39 

Great enlargement of the lymph glands of the neck 
should be thoroughly investigated; there should first be 
an examination of the blood; when this is negative for 
leukaemia, one of the enlarged glands may be removed 
under local anesthesia for microscopic study. 

The diagnosis of leukaemia, Hodgkins Disease, or Reject. 
Lympho-sarcoma rejects the registrant from any military 
service. If the removed gland shows tuberculosis, or the 
registrant should refuse this minor operation he shall be 
accepted for general military service, deferred remediable 
group (Group B), diagnosis large tuberculous glands of 
neck or large glands of neck. 

In all cases of enlarged glands of the neck with or 
without sinus or abscess there should be careful investi- 
gation of the nose, pharnyx, tonsils, and teeth, and the 
relationship between remediable defects found there and 
the lesions of the neck carefully considered. 

BENIGN TUMORS OF THE NECK. 

Outside of thyroid tumors and enlarged lymph glands Accept, 
the most common benign tumors in the region of the neck 
are atheromatous or other forms of cyst. 

Registrants with benign tumors of the neck, or who Accept. 
give a history of the removal of a benign tumor of the 
neck shall be accepted for general military service. 

Registrants with tumors in the region of the parotid Accept. 
or submaxillary glands (the so-called mixed tumors of the 
parotid) shall be accepted for general military service. 

Registrants who give a history of the removal of the 
so-called mixed tumor of the parotid gland shall be 
accepted for general military service even if the opera- 
tion has resulted in facial paralysis. 

MALIGNANT TUMORS OF THE NECK. 

There should be no difficulty in diagnosing a malignant Accept< 
tumor of the thyroid gland, however, when a registrant 
claims to have been operated upon for a malignant tumor 
of the thyroid gland and there are no signs of recurrence 
the Medical Advisory Board must thoroughly investigate 
the records of this operation. Not infrequently enlarged 
thyroid due to chronic thyroiditis or adenoma has been 
diagnosed malignant by the surgeon at the operation or 
by the pathologist from the microscopic section. 

Cancer of the neck arising from the residue of a bran- 
chial cleft is rarely observed in men under 31 years of age. 



40 

This tumor has the same situation as that of the benign 
atheromatous cyst or an enlarged lymph gland behind 
the strenol cleido mastoid and below the parotid gland. 
The differential diagnosis in the early stage can not be 
made. Registrants therefore with a tumor in this area 
should be accepted for general military service, deferred 
remediable group (Group B), and diagnosed doubtful 
tumor of neck. 



CONTRACTION OF THE MUSCLES OF THE NECX- 
COLLIS OR WRY NECK. 



TORTI- 



Accept. 



Reject. 



Test of lungs. 



Registrants with nonspastic contraction of the muscles 
of the neck shall be accepted for general military service 
when the resultant deformity is not so disfiguring that 
it is unsightly or not of such a great degree that it will 
interfere with the wearing of a soldier's uniform or the 
duties of a soldier. 

When the contractions are of a degree rendering the 
registrant unfit for general military service but in the 
judgment of the Medical Advisory Board remediable by 
operation, the registrant shall be accepted for general 
military service, deferred remediaable group (Group B), 
with diagnosis torticollis. 

When the defect is not remediable by operation the 
registrant shall be accepted for limited military service 
or rejected according to the judgment of the Medical 
Advisory Board. 

A spastic form of spasmodic contraction of the muscles 

of the neck shall reject the registrant from all military 

service. 

XI. LUNGS. 

Regulations for Local Boards. (Section 184 (i), S. S. R.) 

The examination of the lungs by the physician on the 
Local Board should in all instances include the following 
procedures : 

Each registrant should be required to exhale his breath, 
cough, and immediately breath in. The chest should be 
auscultated during this process. All men who show 
moist sounds during cough or during respiration should 
be referred to the Medical Advisory Board. 

All registrants should be referred to the Medical Ad- 
visory Board in whom at this examination there is well- 
marked dullness on percussion, increased transmission 
of the voice, harsh respiration, and prolonged expiration 



41 

even though there be no rales present. Men distinctly 
under weight or with sunken and deformed chests should 
be referred to the Medical Advisory Board, even if the 
examinations above noted are negative. 

Accept registrants when the examinations noted above Acoe P*- 
are distinctly negative, and the physician of the Local 
Board is of the opinion that there is no evidence of dis- 
ease of the pleura, lungs, and mediastinum. 

Refer all other cases to the Medical Advisory Board. e s2bi!^ed5se? 

Reject no registrants for diseases of the lungs, pleura, 
mediastinum, and chest wall except men with tuber- 
culosis or other diseases of lungs, pleura, and medias- 
tinum who are confined to their beds when verified 
histories establish unmistakably the existence and long 
duration of diseases. 

REGULATIONS FOR MEDICAL ADVISORY BOARD — EXAM- 
INATION FOR TUBERCULOSIS OF THE LUNGS. 

The duties of the examiner are: 

1. To exclude cases of manifest tuberculosis from the 
Army. 

2. To hold to service men who allege tuberculosis as a 
ground for exemption or discharge on the basis of insuffi- 
cient or incorrectly interpreted signs and symptoms. 

Men who desire to serve their country may conceal, 
from patriotic motives, symptoms of tuberculosis which 
they know or suspect to exist. Some tuberculous 
patients will seek enlistment with a view to obtaining 
treatment and a pension. Some soldiers who have vol- 
unteered may repent their action and allege symptoms of 
tuberculosis with a view to securing discharge. Some 
conscripts may be expected to claim the existence of 
tuberculosis as a ground for exemption, and may fortify 
their claims by certificates of physicians and by radio- 
graphs. There will probably be many cases in which 
pulmonary tuberculosis will have been diagnosticated on 
the ground of subjective symptoms and of physical signs 
which are normal or indicate unimportant and healed 
lesions of some kind. 

It is necessary therefore that conclusions of the exam- 
iner shall be based only on physical signs, sputum exam- 
inations, and radiographs. Statements of the subject as 
to symptoms will not be accepted as proof of the exist- 
ence of tuberculosis unless supported by objective 
evidence. 



42 

It is the duty of examiners to protect the interests of 
the Government by preventing men from entering the 
service who have manifest tuberculosis. It is equally 
their duty to prevent the escape from service on the 
ground of tuberculosis of men who present slight or 
doubtful deviations from the normal. It is therefore 
necessary to insist that recommendations for discharge 
for tuberculosis of otherwise apparently healthy and 
vigorous men shall be based only upon the presence of 
definite and plainly marked signs of pulmonary lesions. 

The following signs will not be regarded as evidence of 
pulmonary disease in the absence of other signs in the 
same portion of the lungs: 

1. Slightly harsh breathing, slightly prolonged expira- 
tion over the right apex above the clavicle anteriorly and 
to the third dorsal vertebra posteriorly. The same signs 
at the extreme apex left side. 

2. Same signs second interspace right anteriorly near 
sternum (proximity of right main bronchus). 

3. Increased vocal resonance, slightly harsh breathing 
immediately below center of left clavicle. 

4. Fine crepitations over sternum heard when stetho- 
scope touches the edge of that bone. 

5. Clicks heard during strong respiration or after 
cough in the vicinity of the sternocostal articulations. 

6. The so-called atelectatic rales heard at the apex 
during the first inspiration which follows a deeper breath 
than usual or a cough. 

7. Sounds resembling rales at base of lung (marginal 
sounds), especially marked in right axilla, limited to 
inspiration. 

8. Similar sounds heard at apex of heart on cough 
(lingula) . 

9. Slightly prolonged expiration at left base pos- 
teriorly. 

10. Very slight harshness of respiratory sounds with 
prolonged expiration in the lower paravertebral regions 
of both lungs posteriorly, most marked at about angle 
of scapula, disappearing a short distance above that 
point, equal on both sides, or slightly more marked at the 
angle on one side, more frequently the left. 

The Apices. — Incipient tuberculosis of the apex is 
often erroneously diagnosticated: 

1. On account of misinterpretation of normal sings. 

2. Because the importance of minor ^differences be- 
tween the two sides is exaggerated. 



43 

3. Because signs of a healed lesion are considered* 
to indicate an incipient lesion. 

For No. 1, see No. 1, page 42. 

With regard to No. 2, it is not too much to say that, 
given a sufficiently minute examination, there would 
be few men who would fail to show some signs which 
might be interpreted as having pathological significance. 

No. 3. The truly incipient tuberculosis of the apex 
generally escapes detection when in an active state. 
When healed it constitutes the abortive tuberculosis of 
Bard. Induration of the apex has been described by 
Kronig as a nontuberculous affection. The important 
question here is whether the signs present indicate a healed 
or active process. They are harshness of respiratory 
sounds, prolongation of expiration, increased conduction 
of voice, and more or less dullness on percussion. These 
signs are caused by induration of pulmonary tissue. 
Induration caused by acute inflammation is relatively 
rare in tuberculosis. It is not characteristic of a recent 
but of an advanced process, when present to an extent 
which permits detection by clinical methods. When it 
does occur, the subject is usually febrile and evidently ill. 
In cases of ambulant subjects in apparently good health 
the presumption is that the above signs indicate an old 
not an incipient lesion. The abortive tuberculosis of 
Bard, and Kronig's apical induration, whether or not it 
is due to an obsolete tuberculosis, are not causes for rejec- 
tion in the absence of tuberculous disease at a lower level 
in the upper lobe. Narrowing of Kronig's isthmus is 
extremely common. It is not a sign of recent disease but 
of contraction of the lung from old disease. In considera- 
tion of the frequent asymmetry of the bony structures 
about the apices slight differences in the width of the isth- 
mus on the two sides are unimportant. A distinct con- 
traction of one side points to the existence of a tuber- 
culous focus of the upper lobe; whether or not this focus 
is of clinical importance must be determined from the 
signs in the individual case. Contraction of the isthmus 
per se is not a cause for rejection. The attention of 
examiners is particularly invited to the necessity of 
exercising great conservatism in their interpretation of 
physical signs over the apices. Interpretation of such 
signs as indicating active tuberculosis would in many 
cases do the Government great injustice, leading to the 
exclusion of men who are fit for service. The only trust- 



44 

worthy sign, of activity of apical tuberculosis is the 
presence of persistent moist rales. 

DIAGNOSIS OF TUBERCULOUS LESIONS IN GENERAL. 

The acute lesion. — If small this lesion is manifested by 
rales with or without changes in breath sounds, percus- 
sion note, and voice transmission. The more acute the 
lesion the greater the probability that its presence will 
be indicated only by rales. If of large extent the process 
is distinctly a broncho-pneumonia, generally caseous, 
characterized at first by the usual signs of pneumonia, 
crepitant, and subcrepitant rales; when caseated by ab- 
sence of rales, except coarse and distant rales from the 
larger bronchi, also by impairment of expansibility of 
the lung, and more or less dullness or tympanitic reso- 
nance; when breaking down by cavity signs and the 
presence of loud moist rales of varying size. Large 
acute lesions are rarely found in candidates for enlist- 
ment, and the small acute lesion is also comparatively 
rare. 

The arrested chronic lesion. — It is by no means rarely 
the case that a tuberculous lesion will run its course and 
become arrested without the knowledge of the subject, 
who may state in perfectly good faith that he has never 
had tuberculosis. The arrest of a lesion is indicated by 
the absence of rales. Such a lesion is characterized by 
harshness of breath sounds and prolongation of expi- 
ration, by increased vocal fremitus and resonance, and by 
more or less pronounced dullness on percussion. 

The active, chronic, localized lesion. — Activity is denoted 
by the presence of rales, together with the other signs 
described under the arrested lesion. Rales do not 
necessarily show that the lesion is extending nor that 
the activity is of much clinical importance, but in mili- 
tary practice the presence of rales accompanied by 
breath changes and other signs should be an indication 
for rejection. The more active and recent the chronic 
lesion the less marked the breath changes and the more 
conspicuous the rales. 

Disseminated tuberculosis. — True miliary tuberculosis 
is not likely to come to the attention of the military 
examiner. The peribronchial type is common and fre- 
quently not recognized. In the adolescent the peri- 
bronchial tuberculosis may be extending from the deep 



45 

Jung without as yet developing a superficial focus. It 
may be manifested only by the presence of distant rales 
with or without slight changes in the breath sounds 
which are of slight bronchovesicular quality. If the 
case is well marked there will be impairment of expan- 
sibility of the affected side and increased vocal resonance. 
Less pronounced cases are distinguished from chronic 
bronchitis only by the character of the rales (coarser in 
bronchitis) and by their topical distribution. 

More frequently the peribronchial type is found accom- 
panying a superficial focus. Bronchovesicular breath- 
ing may extend some distance below the limits of the 
superficial focus with or without rales. But the most 
important manifestation of the peribronchial type is 
extension to the formerly sound side. There may be a 
small, obscure, apparently arrested lesion of one side, 
usually the right, with a peribronchial extension involv- 
ing the whole or the greater part of the other lung mani- 
fested only by the presence of rales after expiration and 
cough. 

A definitely demonstrated tuberculous lesion of more Rejection. 
than insignificant size below the apex is cause for rejec- 
tion whether such lesion be active or inactive. 

The method of "expiration and cough." — In ambulant 
afebrile subjects harshness of breath sounds and pro- 
longation of expiration characterize the old and relatively 
dry lesion, while the more acute the process the less 
marked are the breath changes and the greater are the 
conspicuousness and significance of rales. No examina- 
tion for tuberculosis is complete without auscultation 
following a cough. 

It is best executed as follows: Starting from the state 
of rest of the lung the subject forcibly expels the air from 
the lungs, reserving the last portion of the expiration for 
a short cough, after which inspiration im m ediately fol- 
lows, but only enough air is inhaled to return the lung to 
the state of rest. The idea is to diminish the size of the 
bronchi as much as may be by expiration, then to cough 
to stir up forcibly such fluid as may be present in them. 
The moisture is more likely to be moved by the current of 
air and so produce rales when the tubes are of their least 
caliber. This procedure should invariably be employed 
in examinations in order to determine the activity of 
lesions found by other signs and also to detect the ex- 
istence of fresh disseminated tuberculosis. 

40712°— 18 4 



46 

Examination of sputum.^-The presence of tubercle 
bacilli in the sputum is a cause for rejection. Examiners 
should, however, take pains to convince themselves that 
the sputum examined came from the lungs of the person 
under examination. To this end they should insist that 
the sputum be coughed up in their presence or in that of 
the pathologist who makes the microscopical examination. 

Tuberculin. — It is well recognized that a positive reac- 
tion to tuberculin, especially in the young adult, is not a 
proof of the presence of active clinically important 
tuberculosis. Tuberculin only demonstrates activity of 
the tuberculous process in the clinical sense when it can 
be shown to produce a focal reaction. Such reaction is 
not without danger. Since, therefore, tuberculin rarely 
leads to a correct diagnosis and may do injury, its general 
use in the diagnosis of tuberculosis in examinations for 
enlistment is prohibited. 

X-ray. — Only well-marked pathological changes are 
revealed by radioscopy. For the accurate diagnosis of 
tuberculosis recourse should always be had to the study 
of the X-ray negative. It is not of course practicable 
always to use radiography extensively for the determi- 
nation of tuberculosis during the examination of recruits. 
But the X-ray will doubtless be often employed in doubt- 
ful or disputed cases, so that it is necessary to consider 
the rules which should obtain in reading the radiograph. 

Morbid changes in the lungs are shown by shadows due 
to two substances: First, blood; second, fully organized 
connective tissue. Blood imprints a shadow on the 
negative only when present in abundance. The con- 
gestion of lobar pneumonia is typical. Broncho-pneu- 
monia of tuberculous origin may also cast shadows, but 
only when the process is acute, the congestion great. 
Frequently the tuberculous process runs so chronic a 
course that the inflammatory reaction is insufficient to 
congest the lung enough to produce a shadow. The 
shadow of congestion is not sharply outlined; it melts 
away at its borders. 

Connective tissue in the parenchyma of the lung away 
from the hilus is not normally present in sufficient quan- 
tity to retard appreciably the passage of the X-rays 
except as it occurs in connection with and as a part of 
the various tubes, bronchi, blood vessels, and lymphatics. 
As a result of proliferative inflammation connective 
tissue develops as a fibrous thickening of these tubes, 



47 

particularly the bronchi and the lymph vessels, which 
casts a shadow deeper than normal; the older the process 
and the better organized the tissue, the denser the 
shadow and the sharper its outline. Tubercle, casea- 
tions, as such, cast no shadows distinguishable from the 
other tissues of the parenchyma. It has been found 
that cubes, 1 cubic cm. in size, of caseous tubercle 
when embedded in a healthy lung are indistinguishable 
by the X-ray. But if the caseations become calcified 
or are even impregnated abundantly with mineral salts 
they become opaque to the X-ray. In general, and 
especially if one has to do with the shadows of tubes, 
it may be said that fuzziness of outline means acute 
vascular congestion, an active process. On the other 
hand, when the shadows of the tubes are sharp we have 
a process which, if active at all, is at least not charac- 
terized by great acuity, is not congestive. There is 
what is called dry tuberculosis of the lung tissue, which 
inclines to abundant formation of connective tissue, to 
dry caseations and cicatrizations, or to complete trans- 
formation into fibrous tissue, characterized by sharply 
outlined granular spots and by more or less sharply 
marked bands and streaks. Special attention is called 
to the persistence of the sharply outlined dots and lines 
when activity of the tuberculous process no longer exists. 
The sharply outlined thickenings of the bronchi and 
other tubes may be evidence of an old inflammation now 
entirely obsolete, may be simply records of the ancient 
history of the pulmonary tuberculosis. 

We do not see tubercles in the X-ray negatives. What 
we see is either sharply outlined calcifications and fibroses, 
or fuzzy congestions, or a combination of the two con- 
ditions. Cases are seen in which the X ray in general 
gives the same findings in both lungs while the autopsy 
proves one lung severely, the other slightly, diseased. 
Such cases illustrate well the limitations of X-ray diag- 
nosis. What is seen in the X-ray negative is the thick- 
ened framework of old inflammation in the two lungs, in 
one accompanied by much parenchymatous disease of 
recent origin, in the other accompanied by little, the said 
parenchymatous disease being invisible to the X ray 
because neither sufficiently congested nor sufficiently 
organized to cast shadows. 

Extensive systems of lines, many sharply outlined spots, 
or dense streaks do not, then, show an acute process. 



48 

Persons in good health with nearly or quite arrested tu- 
berculosis are sometimes found by the X ray to present 
a picture of very extensive changes of this kind. Yet the 
prognosis in such cases is not good if the subjects be sub- 
jected to severe strain. The radiograph is a proof that 
the lungs have undergone serious changes. The danger 
is either that hardship will lead to a reactivation of the 
numerous more or less quiescent tuberculous lesions, or, 
if the process has been largely of the nature of fibrosis, 
that the lungs have been so damaged thereby as to unfit 
the person for an active life. If then the radiograph 
shows extensive dappled or mossy shadows or numerous 
spots and streaks the recruit should be rejected however 
good his health may appear to be. Shadows of a homo- 
geneous opacity result from pleurisy and are not neces- 
sarily a cause for rejection in the absence of other signs. 

Tuberculosis of the bronchial glands is a diagnosis often 
made from the radiograph on very slight foundation. 
The fact is that pronounced swelling of the lymph glands 
is characteristic of primary, not of advanced tuberculosis. 
It is rare that intrathoracic gland tuberculosis is of any 
clinical importance in the adult. With few exceptions 
cases of bronchial gland tuberculosis which lead to true 
symptoms of disease are confined to the first and second 
years of life. Only rarely, especially in adults, is so- 
called hilus gland tuberculosis a purely glandular process; 
it is rather a more or less pronounced disease of the sur- 
rounding hilus tissue in the form of peribronchial and in- 
filtrative processes of the neighboring pulmonary tissues. 
That is, the interscapular dullness relied upon for the 
diagnosis of enlarged glands, if caused by lung conditions, 
is due to tuberculous processes in the region of the hilus, 
participation in which to any important extent on the part 
of the glands is a matter of conjecture. The presence of 
masses in the neighborhood of the hilus as shown by the 
X ray may indeed be cause for rejection, but rejection on 
account of relatively small opacities in that region on the 
ground that they indicate a bronchial gland tuberculosis 
of clinical importance certainly should not be permitted. 

Resume of indications from X-ray negatives. — The X 
ray shows: 1. Tuberculous disease confined to region of 
hilus in deep lung. 2. Extension upward toward apex 
or downward and outward toward base, confined to deep 
lung. 3. A fine line or two extending to apex with or 
without small focus or foci there — condition not determ- 



49 

inable by physical signs. 4. Clouding of apex without 
marked lines from hilus, probably largely pleuritic. 
5. Well-marked lines extending to superficies of apex, 
usually, but not necessarily, with foci there — lesion acces- 
sible to physical examination. 6. Lines extending 
toward shoulder as well as apex, (a) If confined to deep 
lung may mean early and now obsolete exacerbation. 
(b) If extending to superficies denote larger lesion and 
less immunity than 5. 7. More or less widely diffused 
spots, lines, and streaks through a considerable portion 
of lower lobe approaching periphery of lung, with few 
or no auscultatory signs — deep peribronchial tuberculosis. 
8. More extensive streaked opacities involving greater 
part of one or both lungs and extending to periphery 
with few or many physical signs — fibrocaseous tuber- 
culosis, fibrosis preponderating in proportion to scanti- 
ness of more or less rounded spots or dots. 

Conditions as shown by 1, 2, 3, 4, and 6 (a) are not 
causes for rejection. Cases under 5 are to be determined 
by physical examination. Cases under 6 (5), 7, and 8 
are to be rejected. 

NONTUBERCULOUS DISEASES OF THE LUNGS. 

Accept registrants with acute bronchitis, chronic Aec ept. 
bronchitis unless well marked, and hay fever. 

Accept registrants who give a history of operation for Accept 
empyema if it is more than one year since the healing of 
the wound and the physical examinations of the chest are 
negative. 

Accept registrants for special or limited military service Accept. 
with chronic sinuses of the thorax following operation for 
empyema, well marked chronic bronchitis, and pneumono- 
coniosis. 

Registrants with pleurisy with effusion and no evidence 
of tuberculosis shall be placed among temporary defects 
for reexamination. 

Reject registrants from all military service when the Reject 
following diseases of the lungs can be established by the 
presence of physical signs: Syphilis, Malignant disease, 
actinomycosis, Hydatid disease, abscess, empyema, ex- 
tensive bronchiectasis, fetid bronchitis, bronchial asthma, 
well-marked chronic bronchitis and emphysema, pleurisy 
with effusion. 



50 

Accept. Accept registrants with evidence of fracture of the rib 

or ribs even if there is union with deformity or excessive 
callus formation, providing the local lesion does not inter- 
fere with respiratory movement and the examination of 
the lungs is negative for any disqualifying lesion. 

Accept. Accept registrants with syphilitic periostitis of rib, 

sternum, or clavicle. 

Reject registrants with tuberculosis of the ribs or 
sternum. 

Accept, remedi- Accept registrants for the remediable deferred group 

able deferred. ojt 

group. with post-typhoid periostitis with or without sinus. 

Accept. Accept registrants with benign tumors of the breast or 

diffuse hypertrophy of the breast. 
Reject. Reject registrants with definite signs of cancer of the 

breast or who bring authentic data of an operation for 
cancer of the breast. 
Accept# Accept registrants with small palpable glands of the 

axilla. 

XH. HEART AND BLOOD VESSELS. 

Regulations for Local Board. (Section (184 (j) S. S. R.) 

Test of heart The physician on the Local Board shall make the f ol- 

and blood ves- . * • . ' . 

seis. lowmg examinations of the heart and blood vessels: 

1. The examination should in all cases include: 

(a) Location and determination of character of ape- 
impulse. 

(b) Auscultation of the heart sounds over apex, lower 
sternum, and second and third interspaces to right and 
left of sternum, noting accentuation of sounds and mur- 
murs. 

(c) Inspection of root of neck and upper thorax and 
percussion of first interspace on each side of manubrium 
for evidence of aneurysm. 

(d) Count of radial pulse, observation of its rhythm, 
and palpation of radial arteries for unusual thickening 
or high tension. 

(e) Exercise test: Hopping 100 times on one foot. 
At close count heart rate with stethoscope over apex, lis- 
tening for murmurs and noting how long tachycardia 
and unusual dyspnea persist. After two minutes neither 
should be marked. 

After this examination the Local Board shall accept 
all registrants who come within the standard for uncon- 
ditional acceptance, which is as follows: 



51 

STANDARD FOR UNCONDITIONAL ACCEPTANCE. 

2. Subjects with, apex impulse within the left nipple Acce P ta n c «° 
line and not below the fifth interspace, of normal, not 
heaving character, with normal sounds, free from mur- 
murs, without pulsation or dullness above the base of 

the heart, with regular pulse of normal rate, who have 
no unusual thickening of the arteries or evidence of high 
blood pressure, and who show a normal response to the 
exercise test, may be unconditionally accepted. 

3. The Local Board shall reject all registrants pre- ^J 60 *- 
senting definite symptoms of circulatory failure, viz, a 
combination of breathlessness, marked cyanosis, and 
edema. 

4. All other cases shall be referred to the Medical 
Advisory Board. 

Regulations for Medical Advisory Board. 

The duties of the examiner are: 

1. To exclude from active service in the Army any regis- 
trant affected with disease of the heart or blood vessels 
which impairs his ability to undergo severe bodily exertion. 

2. To accept for service men who have been recom- 
mended for rejection because of supposed defects which 
do not indicate disease and do not impair the individual's 
ability to undergo severe bodily exertion. 

3. To determine the importance of definite defects in 
the case of candidates for special service, not entailing 
severe bodily exertion, and to recommend acceptance 
or rejection for such special service. 

Men who desire to serve their country may from 
patriotic motives endeavor to conceal a known valvular 
lesion which has given no symptoms. On the other hand, 
men drafted for service may allege or feign symptoms to 
obtain exemption. Registrants may be expected to 
present physicians' certificates to substantiate the ex- 
istence of valvular disease. Many of these may be given 
in good faith, because of inadequate knowledge of the 
significance of certain frequent murmurs. 

It is necessary, therefore, that the conclusions of the 
examiner shall be based on objective evidence in the 
widest sense, including both physical signs, cardiac 
rhythm, measurement of the blood pressure, and the 
observed effect of effort. Nevertheless, in the presence 
of questionable signs or symptoms, the history, especially 
of past rheumatic fever, may be a factor in the final 



52 

decision. No statements of the subject, however, will 
be accepted as proof of the existence of a cardio-vascular 
defect, unless supported by objective evidence. 

Since it is the duty of examiners to protect the inter- 
ests of the Government by preventing men from entering 
the service whose circulatory systems may be expected 
to break down under strain, and equally by preventing 
the exemption or discharge of fit subjects because of 
unimportant deviations from the normal, it will be 
necessary for them to exercise every care in the interpre- 
tation of their findings and to bear in mind constantly 
the murmurs and other departures from the supposed 
normal which may occur in perfectly healthy hearts. 

Standard for unconditional acceptance. — Subjects with 
apex impulse within the left nipple line and not below 
the fifth interspace, of normal, not heaving, character, 
with normal sounds, free from murmurs, without pulsa- 
tion or dullness above the base of the heart, with regular 
pulse of normal rate, who have no unusual thickening of 
the arteries or evidence of high blood pressure, and who 
show a normal response to the exercise test, may be 
unconditionally accepted. 

All others who deviate from the above requirements 
in any particular shall be held for further examination, as 
follows : 

1. Those with cardio-vascular disease of sufficient im- 
portance to disqualify for any service. 

2. Those with transient or insignificant abnormalities 
known to occur in perfectly healthy hearts and com- 
patible with severe bodily exertion. 

3. Those with defects sufficient to disqualify for full 
active service, but compatible with special and limited 
military service requiring little bodily exertion. 

Principles of interpretation. — The following principles 
are laid down for the guidance of examiners in their inter- 
pretation of abnormal signs and symptoms. In many 
cases the interpretation must be purely individual and 
based on the cumulative evidence of a number of rela- 
tively slight deviations from the normal. It can not be 
too strongly insisted on that, given a heart of normal size 
and responding normally to effort, any murmur that is 
heard should be considered accidental and insignificant 
unless it can be positively demonstrated that it is a mitral or 
aortic diastolic murmur. It should also be constantly 
borne in mind that the excitement of the examination 



53 

may produce violent and rapid heart action, often asso- 
ciated with a transient systolic murmur, which effects 
may erroneously be attributed to the effects of exertion. 
They will usually disappear promptly in the recumbent 
posture, but the examiner must be shrewd to distinguish 
the excitable individuals and take measures to eliminate 
psychic influences from the test, so far as possible. 

Hypertrophy and dilatation of the heart, — Impulse to 
the left of the nipple line or below the sixth rib and of 
heaving character is cause for rejection. Its cause, either 
valvular disease or hypertension in the majority of cases, 
should be sought for. It should not be made a primary 
diagnosis unless careful examination fails to reveal a 
cause. 

Impulse within these limits, but definitely heaving, or 
relative cardiac dullness extending to the left of the nipple 
line, or more than 4 cm. to right of the median line in 
large, more than 3 cm. in small individuals, should lead 
to careful examination for valvular disease, high blood 
pressure, emphysema, or other cause. Unless such other 
cause can be found, the response to exercise shall be the 
guide. Those cases with normal response to exercise 
may be accepted for special service (3) ; all others shall be 
rejected. 

Valvular diseases. — Cardiac murmurs are the most cer- 
tain physical signs by which valvular disease may be 
recognized and its location determined, but murmurs are 
very frequent in the absence of valvular lesions and may 
occur in perfectly healthy hearts, especially under the 
influence of excitement and exertion. Such accidental 
murmurs are always systolic in time. The most irequent 
are as follows : 

Systolic murmurs. — (a) Those heard at the apex on insignificant. 
excitement, especially when recumbent. 

(h) Those heard over the second and third left inter- 
spaces during expiration, disappearing during forced 
inspiration. These are particularly common in men with 
flexible chests, who can produce extreme forced expira- 
tion and under such circumstances may be associated 
with definite thrill. 

(c) Systolic accentuation of the respiratory murmur, 
especially on inspiration, heard near the apex or over 
the back. 

None of the above shall be considered disqualifying for 
active service, 



54 



Doubtful. 



Significant 



Other systolic murmurs unassociated with enlargement 
of the heart, alteration of the first sound, accentuation 
of the pulmonic second sound, or abnormal response to 
exercise may also be considered as without significance 
but should be noted. 

Loud systolic murmurs, audible at the apex and in the 
left back, if associated with any enlargement of the heart, 
with snapping first sound, or accentuation of the pul- 
monic second sound, shall be cause for rejection. If 
unassociated with these other signs and the response to 
exercise be normal the recruit may be accepted for 
special service (3). 

Systolic murmurs at the base, except as specified above, 
especially those heard in the second right intercostal space, 
require more careful scrutiny. They may be due to 
disease of the aortic valves. In this case they should be 
harsh, conveyed well into the neck, associated with an 
aortic diastolic murmur, with thrill, or with a marked 
enfeeblement of the aortic second sound. Any of these 
combinations shall disqualify. They are more often due 
to dilatation of the aorta, either syphilitic or arterio- 
sclerotic. The other signs of dilatation should then be 
sought — increased dullness in the first and second inter- 
spaces to either side of the manubrium, pulsation in this 
area, accentuation of the aortic second sound. In 
doubtful cases X-ray examination and Wassermann test 
should be obtained. Where a slight systolic murmur in 
this situation is the only abnormal sign and the response 
to exercise normal, giving rise neither to breathlessness 
nor thoracic pain or distress, it shall not disqualify. 
Proved dilatation of the aortic arch, or syphilis of the 
aorta, shall be cause for rejection for active service, but, 
if without symptoms, shall not disqualify for special 
service (3). It shall be noted on the record. Systolic 
murmurs heard over the second and third left inter- 
spaces are almost always accidental and insignificant. 
When loud and harsh, heard over the upper left chest, 
front and back, or associated with thrill during quiet 
breathing, they may indicate congenital cardiac disease 
and shall disqualify. 

Diastolic murmurs. — All diastolic murmurs, at apex 
or base, including presystolic murmurs, shall be con- 
sidered evidence of valvular disease and cause for rejec- 
tion. The secondary signs should be sought for, viz, 
enlargement of one or both sides of the heart, alteration 



55 

of the first or second sound, particularly a snapping 
first sound and accentuated pulmonic second sound in 
mitral disease, and the characteristic pulse of aortic 
insufficiency. In doubtful cases a definite history of 
rheumatic fever may be given weight. The exact 
diagnosis should be noted on the record. 

Aneurism and dilatation of the aortic arch. — Aneurism, Arythmia. 
wherever situated, shall disqualify. 

Aneurism of the thoracic aorta, unless large or placed 
near the anterior thoracic wall or giving rise to pressure 
symptoms, is difficult of detection. Simple dilatation of 
the aortic arch is a diagnosis which can rarely be made 
positively from physical signs alone. Therefore, when 
pulsation above the base of the heart, diastolic shock, 
well-marked dullness laterally to the manubrium, with 
a ringing second sound or a systolic or diastolic murmur 
over the dull area, or tracheal tug, inequality of the 
pupils, difference in the two radial pulses, alteration of 
the voice, or suspicious symptoms suggest the existence 
of aneurism or dilatation, X-ray examination and 
Wassermann test should be obtained. Any considerable 
dilatation of the aorta shall disqualify. Slight dilatation 
with a positive Wassermann reaction shall also dis- 
qualify. Slight dilatation with a negative Wassermann 
reaction shall not disqualify, if it be the only impairment 
and unassociated with symptoms and abnormal response 
to exercise. Precordial or other anginal pain, which the 
examiner is convinced is real, may occur without dyspnea 
and is significant. 

Disturbances of rate and rhythm. — A persistent rate of 
100 or over, when recumbent, should suggest the search 
for exophthalmic goiter, tuberculosis, or other infection, 
which would constitute cause for rejection. A persistent 
rate of 100 or over may persist for a limited time after 
recovery from a recent infectious disease, as typhoid 
fever; it may also accompany minor local infections, as 
pyorrhoea alveolaris, antrum, or sinus infections. Cases 
with rapid action for causes such as these, should be 
accepted and placed in the deferred remediable group. 
(Group B), or examination temporarily deferred. (187 
S. S. R.) Persistent rapid heart action, in the absence 
of proof of these, and unassociated with enlargement of 
the heart, may require study in hospital to determine 
its significance. A constant rate of 100 or more should 
disqualify. Temporary tachycardia on excitement is 



56 

common. If extreme, the decision as to its significance 
must depend on other findings, especially on the response 
to exercise. A reliable history of attacks of severe 
tachycardia in the past, with any breathlessness on exer- 
tion, should be reported to the camp surgeon with re- 
quest for watching of the recruit during his training. 

A persistent rate of 50 or under suggests heart block 
and this should be decided by tracings. Heart block 
shall disqualify. Slow rate with normal rhythm and 
normal response to exercise shall not disqualify. Com- 
plete irregularity of the pulse indicates auricular fibrilla- 
tion and shall disqualify. It is not compatible with 
normal response to exercise. 

Occasional extra systoles or premature beats, if the 
heart be of normal size and the response to exercise normal, 
are of no significance. Very frequently extra systoles 
or premature beats require examination to determine 
if they are temporary. When persistent, but the only 
impairment, they should be reported to the camp surgeon 
with request for watching of the recruit during his train- 
ing. 

The irregularity (sinus irregularity) which consists in 
a quickening of the rate during inspiration and slowing 
during expiration is common in the young and is of no 
significance. It may be recognized most easily with the 
subject recumbent and breathing deeply. 

Arteriosclerosis and hypertension. — All subjects with 
thickened arteries, apparently tense pulse and accentua- 
tion of the aortic second sound, shall have their blood 
pressures recorded when lying quietly, the systolic pres- 
sure by the palpatory and auscultatory, the diastolic by 
the auscultatory _ method. A systolic pressure of 200 
mm. Hg. or over or a diastolic of 120 mm. Hg. or over 
shall disqualify. A systolic pressure persistently above 
160 mm. or a diastolic above 100 mm. shall disqualify for 
active service, but if this be the only impairment, the 
recruit may be accepted for special and limited service 
(3). The urine should always be tested for albumen in 
these cases. 

Simple thickening of the arteries without high blood 
pressure or enlargement of the heart and with normal 
response to exercise shall not disqualify. 

Other conditions. — Cases with unusual findings, not 
covered by these instructions, may be determined on the 
general principle that, if the heart be not enlarged and 



57 

its response to effort be normal, it shall not disqualify. 
If the response to effort be impaired, but the heart nor- 
mal in every other respect, ■ and if the subject has not 
been capable in the past of ordinary active exercise, he 
should be accepted for special service (3) or reported to 
the camp surgeon for observation during his training. 

BLOOD VESSELS. 

Registrants who claim to suffer from intermittent Accept 
claudication and whose pulsation in the peripheral 
vessels about the ankle is present shall be accepted for 
general military service. 

Registrants with the objective signs of Raynaud's Reject, 
disease or erythromelalgia shall be rejected. 

THROMBOPHLEBITIS, UPPER EXTREMITY 

Accept as physically qualified for general military 
service registrants who give a history of thrombo- 
phlebitis of one extremity, provided it is one year since 
the onset of the disease and provided that the examina- 
tion shows no swelling and no loss of function. 

Accept as physically qualified for special or limited 
military service all other cases of thrombophlebitis of one 
upper extremity. 

THROMBOPHLEBITIS, LOWER EXTREMITY. 

Accept as physically qualified for general military 
service registrants who give a history of thrombo- 
phlebitis of one extremity, provided it is three years 
since the onset of the disease and provided that the 
examination shows no swelling and no loss of function. 

Accept as physically qualified for special or limited 
military service all other cases of thrombophlebitis of 
one limb. 

Reject as physically deficient and not physically quali- 
fied for military service all registrants with a history of 
or evidence of thrombophlebitis of both lower extremities. 

XIII. ABDOMEN. 



1. Regulations for Local Board. (Section 184 (k) S. S. R.) 

Accept all registrants who after an inspection, per- 
cussion, and palpation of the abdomen show no enlarge- 
ment of the fiver and spleen and no tumor of the abdomi- 
nal wall or within the abdomen. 



Accept, 



58 

Accept. Accept all registrants who give a history of abdominal 

trouble suggesting a chronic appendicitis or gall-bladder 
disease and who on examination present no signs of such 
diseases. 

Accept. Accept all registrants with small or medium reducible 

inguinal, femoral, umbilical, and post-operative hernia. 

Accept. Accept all registrants with abdominal scars who give 

a history of operation for hernia, appendicitis, gall-blad- 
der disease, or for some abdominal injury, providing there 
is no large hernia in the scar. 

Refer to the Medical Advisory Board all registrants 
who have jaundice, who have enlargement of the liver 
or spleen or palpable tumor of the abdominal wall or 
within the abdomen. 

Refer to the Medical Advisory Board all registrants 
who from history and examination suggest very strongly 
the presence of a gastric or duodenal ulcer or some seri- 
ous intra-abdominal disease. 

Refer to the Medical Advisory Board all irreducible 
hernia and all very large hernia. 
Reject no abdominal cases. 

Kidney. When during the examination of the abdomen a kidney 

is palpable and even movable, if it is not enlarged, ac- 
cept the registrant. If it is distinctly enlarged, refer to 
the Medical Advisory Board. 

2. Regulations for Medical Advisory Board. 

When abdominal scars of previous operations are found 
the patient shall be questioned as to the nature of the 
operation performed, and when necessary authentic data 
as to the nature of the operation shall be obtained in any 
way that seems best to the Medical Advisory Board. 

The registrant shall be questioned to elicit positive or 
negative evidence of previous or present abdominal 
trouble. 

Further examination should be regulated by the history 
and the result of the examination by inspection, palpation, 
and percussion. 

COMPLETE EXAMINATION. 

When necessary, the examination may be completed 
as follows : Blood count, Wassermann, gastric lavage for 
the chemical and microscopic examination and gastric 
residual; the examination of the rectum by the finger 
and the rectum and lower sigmoid by the proctoscope; 



59 

the chemical and microscopic examination of the stools ; 
X-ray pictures of the abdomen for the presence or absence 
of stone in the kidney or gall bladder, X-ray pictures and 
fiouroscopic examination after bismuth per mouth or 
per rectum, and the complete examination of the urine. 

3. Method and order of examination. 

The Medical Advisory Board is urged in all abdominal 
cases before proceeding to the more difficult and time- 
taking method to exhaust the possibilities of detecting 
the presence or absence of abdominal lesions by a thor- 
ough physical examination by inspection, palpation and 
oscultation, and by a studious consideration of the reg- 
istrant's positive or negative history. 

CAUTION IN REGARD TO THE DIAGNOSIS OF AN ABDOMINAL 

TUMOR. 

Some registrants purposely retain the urine so that at 
the examination a tumor due to the distension of the 
urinary bladder may be palpated; therefore, in all such 
cases the examination of the abdomen shall be considered 
incomplete until the registrant has passed urine before the 
examiner of the Medical Advisory Board or, in case of 
any doubt, a catheter has been passed through the urethra 
into the bladder and such a voluntary retention of urine 
demonstrated. 

It must also be remembered that in some cases the 
abdominal tumor may be due to retention of the urine 
through no purposable act of the registrant, but due to 
fright or some lesion of the urethra or prostate, or to some 
lesion of the nervous system. All of these facts must 
be considered in cases of this kind. 

4. Hernia. 

All other types and degrees of hernia not mentioned in 
the regulations for the Local Board shall be carefully 
studied by the Medical Advisory Board. If after this 
examination it is the opinion of the Medical Advisory 
Board the hernia is remediable by operation and the 
registrant is otherwise physically fit, the registrant shajl 
be accepted for general military service in the deferred 
remediable group (Group B) and diagnosed hernia. 

If it is the opinion of the Medical Advisory Board the 
hernia is not remediable by operation or the probability 
of a successful operation is small, the registrant, if other- 



60 

wise physically fit, shall be placed in the group as physi- 
cally qualified for special or limited military service. 
(Group C.) 

Registrants with hernia of any type so large, reducible 
or irreducible, apparently not remediable by operation with 
a large probability of a successful result, and who on ac- 
count of this hernia show every evidence of being in- 
capacitated, they shall be declared physically deficient 
and not physically qualified for military service by rea- 
son of an irremediable disqualifying hernia. 

The Medical Advisory Board must remember that in 
men under age 31 the majority of all types of hernias are 
remediable by operation. 

The most difficult hernias to cure are the very large 
post operative hernia and inguinal, femoral hernia which 
have recurred once or more frequently after operation. 

SCAR PAIN. 

Accept Registrants who have been operated upon for any type 

of hernia or registrants with small post operative hernia 
who claim that they have scar pain who are otherwise 
physically fit shall be accepted as physically qualified for 
general military service. 

IRREDUCIBLE HERNIA. 

It is to be remembered that because the apparent 
hernia is irreducible this of itself is not evidence that the 
hernia is not remediable by operation. 

Umbilical hernias are frequently irreducible because the 
sac contains adherent or retained omentum. Femoral 
and inguinal hernias are often irreducible because the sac 
contains walled-off fluid or retained or adherent omentum. 

Accept operable irreducible hernia for general military 
service deferred remediable group. (Group B.) 

The association of inguinal hernia with undescended 
testicle with varicocele or hydrocele is not a cause for 
rejection. 

5. Appendicitis. 

* Registrants who at the examination show the definite 
local signs of an acute or subsided appendicitis shall be 
allowed a reasonable time for recovery. (See Temporary 
defects, section 187, S. S. R.). 

Registrants confined to their homes or to a hospital 
waiting operation for appendicitis or convalescing from 



61 

an operation from appendicitis or recovering from an 
attack of appendicitis shall be given a reasonable time 
before being subjected to a physical examination by the 
Medical Advisory Board. 

Registrants who have been operated upon for appendi- Accept, 
citis with or without drainage and who complain of scar 
pain, if otherwise physically fit, shall be accepted for 
general military service. 

Registrants who give a history of operation for appen- 
dicitis with or without drainage and who since this opera- 
tion have had one or more definite attacks of intestinal 
obstruction relieved with or without operation, if these 
data can be confirmed by authentic records, should be 
given a complete abdominal examination. When this 
examination is complete and the authentic records have 
been carefully considered, the Medical Advisory Board 
shall accept such a registrant as physically qualified for 
general military service when, in their opinion, the proba- 
bility of further attacks of intestinal obstruction are very 
slight. 

If, in their opinion, the probability of further attacks of 
the obstruction are not slight, the registrant shall be 
rejected. 

6. Gall bladder disease. 

Registrants who at examination show definite local 
signs of acute subsiding or chronic cholecystitis with or with- 
out j aundice and registrants confined to their homes or to a 
hospital waiting operation for gall bladder trouble with or 
without jaundice or convalescing from an operation or 
recovering from an attack shall be given a reasonable 
time before being subjected to an examination by the 
Medical Advisory Board. 

Registrants who give a history of one or more attacks 
of what suggests cholecystitis with or without jaundice 
and who at examination show no local symptoms or but 
slight local symptoms shall be subjected to. a complete 
abdominal examination. When the diagnosis by the 
Medical Advisory Board is cholecystitis without jaundice, Accept, 
and the registrant is otherwise physically fit, he shall be 
accepted as physically qualified for general military 
service. 

Registrants who give a history of an operation upon the Accept, 
gall bladder (drainage or removal of the gall bladder) or 
the history of removal of stones from the common duct 
40712°— 18 5 



Jaundice, 



and who at examination are free from jaundice and 
apparently relieved from the former trouble shall 
accepted as physically qualified for general military 
service. Those who complain of scar pain shall also be 
accepted. Those who complain of definite recurrent 
attacks with or without jaundice shall be given a thorough 
abdominal examination, after which the Medical Advisory 
Board shall use their own judgment as to whether they 
shall be accepted as physically qualified for general 
military service or accepted for general military service, 
deferred remedial group (Group B) . 

7. Jaundice. 

Registrants who show the signs of jaundice based upon 
the color of the skin, bile in the urine, and clay-colored 
stools, shall be subjected to a complete abdominal examina- 
tion. Such registrants shall not be accepted for either 
general or special military service until the jaundice has 
disappeared or until the cause of the jaundice has been 
ascertained. 

Catarrhal jaundice as a rule disappears in from two to 
three weeks. Jaundice associated with cholecystitis or 
pancreatitis as a rule disappears within a few weeks; hence 
registrants with this type of jaundice can be reexamined 
after the jaundice disappears. 

The examination of registrants with jaundice shall be 
temporarily delayed until the jaundice has disappeared, 
but for not more than two months. When the jaundice 
disappears they shall be reexamined in the ordinary way. 
.If the jaundice persists, they shall be declared as unfit 
for any military service. Registrants with jaundice and 
a plus Wassermann should be advised to receive salvar- 
san and the usual antisyphilitic treatment during the 
period of delay. No case of persistent jaundice should 
be accepted for general military service or for special or 
limited military service. 

8. Intestinal obstruction. 

The relation of intestinal obstruction to appendicitis 
has been discussed. 

Excluding these causes of intestinal obstruction, this 
lesion is rare in men between the ages of 21 to 31. 

Registrants who give a history of one or more attacks 
of intestinal obstruction with or without authentic data 
should receive a thorough examination, and if the find- 
ings are negative, should be accepted for general military 



63 

service. If the examination brings out any objective 
findings, indicating a definite intraabdominal lesion, 
other than hernia or appendicitis, the registrant should 
be placed in the deferred remediable group (Group B). 

Registrants who give a history of an operation for 
intestinal obstruction from causes other than hernia or 
appendicitis should furnish authentic data. 

If the cause of this obstruction was apparently re- Accept, 
moved at this operation and the registrants have been 
free from definite attacks since, the registrant should be 
accepted for general military service. 

When the cause of the intestinal obstruction revealed 
at operation was some irremediable disease such as tuber- 
culous peritonitis, or cancer of the colon (tumor not re- 
moved), the registrant should be rejected unconditionally. 

Registrants who have had previous operations may 
complain of scar pain, or they may have been told that 
they have adhesions. A sharp distinction should be 
made, if possible, from such scar pain and such abdominal scar pain. 
discomfort supposed to be due to adhesions and definite . 
attacks of intestinal obstruction. 

Scar pain and discomforts due to abdominal adhesions Accept, 
are of themselves not causes for rejection. Individuals 
not subject to the selective draft often exaggerate the 
discomforts of scar pain and supposed intestinal adhesions. 
Registrants may in some instances attempt to claim for 
disability on account of scar pain and intestinal adhesions, 
following some former operation. 

Long experience with observations of this kind clearly 
demonstrates that scar pain and discomforts supposed 
to be due to an intestinal adhesion with negative find- 
ings at a careful examination do not incapacitate the 
individual from heavy physical work in civilian occupa- 
tions and therefore should not incapacitate them from 
general military service. 

9. Stomacn, duodenum, and colon. 

Registrants may complain of weak stomach, indiges- 
tion, dyspepsia, constipation, belching, vomiting, various 
types and degrees of abdominal discomfort; they may 
claim that they have been told that they have a gastric 
or duodenal ulcer or other chronic inflammation of the 
gastro-intestinal tract, or ptosis of the stomach and colon; 
they may give the history of an operation other than for 
hernia, appendicitis, gall-bladder disease, or intestinal 
obstruction. 



64 

The registrant may give such a definite history as the 
vomiting of blood or the passing of blood per rectum. 

In cases of this kind it may be necessary to make a 
complete abdominal examination before coming to a 
definite conclusion. In order to facilitate this, not only 
for economy of time but for certainty of results, an order 
of the examination should be adopted which will accom- 
plish this. 

Before proceeding with the complete examination of the 
abdomen the following examination should be made first: 

ASSOCIATED DISEASES. 

The registrant may have lesions without the abdomen, 
which may have some causal relation to the abdominal 
condition, or whether they are causal or not may of them- 
selves place the registrant as physically disqualified for 
military service, or in the group for limited or special 
military service. For this reason weigh and measure 
the registrant, examine the heart, lungs (especially for 
tuberculosis), and urine first. Then examine the blood. 

Examine the nose, throat, mouth, and teeth for focal 
infection; examine the thyroid and look for toxic symp- 
toms. 

Examine the pupils and reflexes for the presence of 
signs of organic diseases of the nervous system. 

When the registrant passes all other examinations 
within the standard of unconditional acceptance, with or 
without remediable defects, or when no lesion has been 
found which places the registrant in the group for limited 
military service, proceed with the complete examination 
of the gastro-intestinal tract as follows : 

Inspection. — Inspection of the abdomen may reveal 
tumors, and in emaciated individuals the outlines of the 
stomach may be visible, also peristalitis of the stomach and 
intestines in cases of p}doric stenosis or intestinal tumors. 

Palpation. — Superficial palpation may give important 
information regarding the location of tender areas, or 
muscular rigidity over the stomach, intestines, gall 
bladder, and appendix. Deep palpation may locate 
and determine the size of the abdominal tumors. The 
effort should be made to palpate the liver, spleen and 
kidneys in every case. 

Fecal masses may simulate abdominal tumors, making 
it necessary to clear out the intestinal tract with a 
laxative before the second examination. An expensile 



65 

or pulsating aorta has been known to be mistaken for 
an areurysm, or abdominal tumor. 

Percussion. — In every examination of the abdomen, 
percussion should be employed to outline the size of the 
liver and spleen and to ascertain whether a palpable 
tumor is dull or tympanic. Percussion is the best method 
of demonstrating whether there is encysted or free fluid 
in the peritoneal cavity. 

Auscultation. — This method may be employed to out- 
line the stomach and colon. However, the X-ray plate 
or fluoroscopy is the most accurate method for outhning 
the position and the size of the stomach and colon. 

10. The laboratory investigations in gastrointestinal lesions. 

Test meal* — When it seems necessary or advisable, 
and the registrant consents to the procedure, the Ewald 
or the Dock test breakfast should be given, to be removed 
in an hour by the expression or aspiration method. 

The fasting stomach. — The examination of the contents 
of the fasting stomach (before breakfast) is of great im- 
portance in suspected ulcer, carcinoma, and gastrectasis 
from other causes. 

Value of chemical examination of stomach contents in 
ulcer and carcinoma. — The chemical examination of the 
stomach contents is of much value in making the diag- 
nosis of ulcer and carcinoma of the stomach, as it is 
in many other gastric diseases. Hyperchlorhydria does 
not always mean ulcer, nor does achlorhydria necessarily 
indicate carcinoma; but in ulcer, except in the long- 
standing cases, there is usually an increase in hydrochloric 
acid; and in the great majority of cases of carcinoma of 
the stomach there is absence of hydrochloric acid, and 
the presence of lactic and other organic acids, in the 
stomach contents. Therefore, when there are subjective 
symptoms of ulcer, with a hyperchlorhydria and the 
presence of occult blood in the stools, the diagnosis of 
ulcer is probable; and when there are other evidences of 
gastric carcinoma the absence of hydrochloric acid and 
the presence of lactic acid is certainly suggestive. 

Hyperacidity and achylia. — It should not be forgotten 
that hyperacidity may occur in gall stones, chronic ap- 
pendicitis and gastric neuroses; and that achylia may 
occur from chronic catarrhal, or atrophic gastritis, and 
as a functional condition. The chemical examination is 
of value only when considered with symptoms and other 



66 

laboratory findings, just as the presence of albumin in 
the urine, without other examination, does not make 
certain the diagnosis of nephritis. 

Blood.— The constant presence of blood in the stomach 
contents, unless the patient retches when the tube is 
introduced, is suggestive of ulcer or carcinoma. 

Microscopic examination of stomach contents. — The 
microscopic examination of stomach contents is not of a 
great deal of value in the examination of men of the 
draft age, though occasionally particles of ulcer or cancer 
tissue may come up through the tube. The Boas-Oppler 
bacillus is found in the stomach contents in 90 per cent 
of the cases of gastric carcinoma. This bacillus has also 
been found in the stagnant contents of the stomach in 
which lactic acid was also present, in cases of simple 
gastrectasis. Blood and pus cells are usually present in 
the stomach contents, even in the early stages, of gastric 
carcinoma. 

THE FECES. 

When indicated, the feces may be examined for occult 
blood and parasites. Further examination of the feces 
is left to the discretion of the Medical Advisory Board. 

X-RAY EXAMINATIONS. 

The X ray, while not infallible, is the most important 
aid in the diagnosis of gastrointestinal diseases. It gives 
information regarding the size, contour, position, and 
muscular function of the stomach and intestines that can 
be obtained from no other source. _t is therefore ad- 
visable, but not essential, in cases of suspected ulcer or 
carcinoma, or in gastroenteroptosis, for the registrant to 
be given the benefit of an X-ray examination, provided 
that a competent rontgenologist is available. The in- 
terpretation of rontgenoscopic or rontgenographic find- 
ings is of the greatest importance. It is often better 
to have no X-ray examination than to have it done by a 
man of limited experience, or with an inferior rontgeno- 
logical outfit. 

When the examiner has had the experience, fluoroscopic 
examinations with the X rays should be made first, and 
plates only taken when necessary. 

In the large majority of cases it may be safer to take 
one plate of the abdomen first before the bismuth meal 
is administered. The object of this plate is to reveal or 



67 

exclude stome in the ureter or kidney, gall-stones, calci- 
fied mesenteric glands, or any changes in the bones of the 
vertebrae and pelvis. If present, this plate will also show 
enlargment of the liver, spleen, and kidney. 

11. Conclusions from findings of complete examination. 

These laboratory investigations in gastrointes- 
tinal LESIONS REQUIRE TIME AND TO BE OF VALUE 
MUST BE EXACT. THE MEDICAL ADVISORY BOARD 
SHOULD USE ITS OWN JUDGMENT AS TO WHEN THESE 
LABORATORY INVESTIGATIONS SHOULD BE MADE. 

It IS IMPORTANT TO EMPHASIZE HERE THAT OF ALL THE 

laboratory tests just outlined, the estimation 
of gastric residuum on a fasting stomach is perhaps 
more important than the chemistry of the material 
withdrawn from the stomach after a test meal. 

Registrants with definite gastric residuum due 
to some remediable defect should be accepted 
for general military service in the deferred 
remediable group. (group b.) 

Registrants with definite blood in the gastric 
contents should be held in the group of temporary 
defects, section 187, s. s. r., and then if it does 
not disappear after a reasonable time, be accepted 
for general military service in the deferred 
remediable group (group b) if in the opinion of the 
Medical Advisory Board the cause of the blood 
is remediable 

Registrants whose feces show occult blood 
in repeated examinations should be accepted for 
general military service if the cause of the blood 
is due to some simple defect which comes within 
the standards of unconditional acceptance, as 
hemorrhoids, small superficial ulcer of the 
rectum, fissure or any of the intestinal parasites. 
In other cases, when the cause of the blood is 
apparently due to some remediable defect such as 
gastric or duodenal ulcer the registrant shall 
be accepted for general military service in the 

DEFERRED REMEDIABLE GROC/P (GROUP B) . In DOUBT- 
FUL CASES THE REGISTRANT CAN BE HELD FOR FURTHER 
EXAMINATION IN THE GROUP OF TEMPORARY DEFECTS. 

See section 187, S. S. R. 

Registrants who complain of indigestion, dyspepsia. Accept. 
weak stomach, constipation, abdominal pain, belching of 



68 

gas, or other subjective symptoms, in which this thorough 
examination is made, and found negative of organic 
disease, shall be accepted for general military service. 
Accept. Registrants who complain of the above symptoms and 

show at the examination slight ptosis of the stomach, 
colon, or both, with no other objective findings, shall be 
accepted for general military service. 

12. Achylia gastrica. 

Accept. Registrants with, this definite finding in the gastric 

analysis in which there is associated secondary anemia, 
under weight, diarrhea, and nervous symptoms, should 
be placed in deferred remediable group. (Group B.) 

13. Gastric succorrhea. 

Accept. Continuous or periodic gastric hypersecretion must 

depend upon the demonstration of gastric residuum. If 
the X ray shows pyloric obstruction or any other ev- 
idence of an operable benign lesion as its cause, the reg- 
istrant should be placed in the deferred remediable 
group. (Group B.) 

14. Pellagra. 

Accept. It is probable that many incipient pellagrins will be 

accepted for general military service hj both the local 
and medical advisory boards because the examination 
reveals no objective symptoms. Such registrants shall 
be accepted for general military service. 

The most important symptoms of pellagra are burning 
sensation in the mouth, pyrosis (heartburn), vague dis- 
comfort or even pain in the abdomen, diarrhea in 90 per 
cent of the cases, and burning sensation in the rectum. 
The skin symptoms are not pronounced during the 
winter months, and the digestive symptoms may occur 
without the dermatitis on the dorsal surfaces of the 
hands, feet, and elbows. 

Pellagra does not disqualify for military service unless 
the registrant is bedridden or has pronounced psycho- 
pathic symptoms, and even then the disqualification is 
only temporary, because pellagrins, even in what was 
formerly considered the advanced stage, with proper diet 
and treatment usually made rapid and complete recovery. 

Accept for general military service in the deferred re- 
medial group (Group B) registrants with pellagra in ad- 
vanced stages who are temporarily incapacitated. 



69 

15. Gastric ulcer. 

The diagnosis of gastric ulcer must depend upon veri- 
fied history and objective findings in the gastric contents 
and on gastric residuum, on stools, and on the X-ray study. 
Registrants exhibiting the objective findings of an acute 
or chronic gastric ulcer should be placed in the de- 
ferred remediable group. (Group B.) 

Registrants who give a verified history of gastric ulcer 
without operation should be accepted for general mil- 
itary service if they present no objective findings at the 
present examination, and have been without symptoms 
for six or more months. Otherwise advise Local Board 
to temporarily defer for reexamination, 187, S. S. R. 

Registrants who have been operated upon for gastric 
ulcer must present authentic records of the findings at 
the operation and of the method of operation. 

Registrants who have been operated upon for gastric 
ulcer by the Finney p}'loroplasty or by resection of the 
pylorus with a Kocher anastomosis, and who are appar- 
ently well and present no definite objective findings at 
the examination, and when it is at least six months since 
the operation, shall be accepted for general military 
service. Otherwise advise Local Board to temporarily 
defer for reexamination, 187, S. S. R. 

When the operation has been a gastroenterostomy 
with or without resection, and when the registrants are 
apparently well, with no objective findings, and it has 
been six months since the operation, they shall be ac- 
cepted for general military service (Group A) , or special 
or limited military service (Group C), according to the 
judgment of the Advisory Board. 

Registrants who have not been relieved by operation 
and who still have objective findings shall be placed 
in the group for limited or special military service. 
(Group C.) 

16. Duodenal ulcer. 

The rulings in regard to duodenal ulcer shall be iden- 
tical with those just given for gastric ulcer. 

17. Gastric cancer. 

Under the age of 31 this lesion is rare. It is often 
impossible to make the diagnosis clinically. 

When the registrant claims to have been operated upon Reject. 
for gastric carcinoma and furnishes authenticated data, 
he shall be rejected as not physically qualified for military 
service by reason of carcinoma of the stomach. 



Accept. 



70 

Reject When the examination suggests the large probability 

of carcinoma of the stomach, he shall be rejected. 

18. Colon— Intestinal stasis. 

Registrants who claim a previous resection of right 
portion, or more, of the colon, or some form of ileo-colos- 
tomy with anastomosis, should have this claim verified 
bv the Medical Advisorv Board, by means of a fluoro- 

Reject, or Group " . " \ * ttti ,i 

c. scopic examination or X-ray plate. When there is no 

doubt as to the resection or anastomosis, the registrant 
shall be rejected (Group D), or placed in the group for 
limited or s|3ecial military service (Group C), according 
to the degree of relief from symptoms, his weight and 
present ability to pursue his civil occupations. 

Registrants who claim symptoms or who claim to have 
been treated for gastroptosis, enteroptosis, nephroptosis, 
or general ptosis of the abdominal viscera or the so-called 
intestinal stasis or registrants who claim to have been 
operated upon for any of the enumerated conditions and 
in which the operation was not a resection of the colon or 
an ileo-colostomy shall be accepted for general military 
service unless there are objective findings other than 
ptosis. 

The regularity of habits, physical exercise, and the 
outdoor life should render the majority of these condi- 
tions remedial by camp life. 

It has been definitely proven that the position of the 
stomach and intestines has nothing or very little to do 
with digestion or health of the individual. 

The majority of cases with extreme symptoms will be 
underweight and will show objective findings. 

* 19. Colon and rectum carcinoma. 

The suggestion of this lesion will be a history of one 
or more attacks of intestinal obstruction, marked con- 
stipation or diarrhea, and blood in the stools. The ob- 
jective findings are the palpation of an abdominal tumor 
or the ulcerated mass per rectum, the inspection of an 
ulcerated tumor through the proctoscope. 

Secondary anemia and loss of weight may accompany 
cancer of the colon, but are not of themselves diagnostic. 

When the supposed carcinoma can not be felt per 
rectum or be seen with the proctoscope, an X-ray exam- 
ination should be made. In cancer of the colon at the 
sigmoid and above, the bismuth picture should show a 
definite narrowing of the lumen of the colon. 



71 

Irrespective of symptoms, some positive objective 
finding must be obtained before even a tentative diag- 
nosis of cancer of the colon can be made. 

When the diagnosis of cancer of the colon is made by Reject. 
palpation per rectum or inspection per proctoscope, the 
registrant shall be rejected. When the diagnosis is based 
upon the palpation of the abdominal tumor or the X-ray 
examination, the registrant may be placed in the deferred 
remediable group (Group B), or rejected, according to 
the judgment of the Medical Advisory Board. 

Registrants who bring verified data that they have 
had an exploratory operation for an inoperable carci- 
noma of the colon should be subjected to the same ex- 
amination as if they have had no such operation, because 
if this claim is correct there will be definite objective 
findings. 

Registrants who bring verified data that they have Acce P*- 
been operated upon for a cancer of the colon and that 
this operation had consisted of resection of a portion of 
the colon and anastomosis should be accepted for gen- 
eral military service if three years or more have passed 
since the operation and they are apparently well. Other 
cases should be placed in the group for limited or special 
military service. (Group C.) 

Registrants who bring verified data that they have Re i ec k 
been operated upon for cancer of the rectum or lower 
colon from below or by the combined sacral and abdom- 
inal method shall be rejected. 

20. Colon— Colitis— Proctitis. 

The diagnosis of either of these lesions must rest upon 
definite objective findings. Diarrhea of itself, with or 
without blood, is not a cause for rejection, but simply an 
indication for a thorough examination. So-called mucous 
colitis without objective findings is not a cause for 
rejection. 

In cases of this kind there must be a thorough examina- 
tion with the proctoscope. If there are numerous polypoid 
growths, with or without ulceration, the registrant shall 
be placed in the group of special or limited military serv- 
ice (Group C), or rejected, according to his ability to 
work. 

If there is a single ulcer, carcinoma and tuberculosis 
must be excluded, by microscopic study, and syphihs by 
a Wassermann and the therapeutic use of salvarsan. 



Doubtful. 



72 

Accept registrants with ulcers of rectum and sigmoid 
which are neither malignant nor tuberculous. 

21. Examination of stools. 

When indicated the feces shall be examined. The 
presence of blood is not a cause for rejection, but simply 
an indication for a thorough examination as to its cause. 

The presence of intestinal parasites of any kind in the 
stools does not disqualify, and registrants should be 
accepted for general military service. 

22. Liver. 

Moderate enlargement of the liver without any other 
objective findings shall not disqualify. 
Reject. A huge enlargement of the liver shall of itself render 

the registrant unfit for any military service. 

Enlarged or atrophied liver with jaundice and fluid 
in the peritoneal cavity disqualifies if the Wassermann 
test is negative. If the Wassermann test is positive, the 
patient should be placed in the group of temporary 
defects (Sec. 187, S. S. R.), until the result of appropriate 
antisyphilitic treatment is established. The majority of 
these cases, however, are not relieved and should be 
rejected. 

LIVER ABSCESS. 

Accept. Registrants who bring a verified history of an opera- 

tion for an abscess of the liver shall be accepted for 
general military service if it is more than six months 
since the operation and they are apparently free from 
objective symptoms. Otherwise reject. 

Registrant with definite objective symptoms of abscess 
of the liver should be held as temporary defects. (Sec. 
187, S. S. R.) 

23. Spleen. 

Accept. Moderate enlargement of the spleen with no other 

objective findings shall not disqualify, but the blood of 
such registrants should be examined for malaria. If the 
Plasmodium is found the registrant shall be accepted for 
general military service. (Group A.) 

Reject. A huge enlargement of the spleen shall reject. 

When the spleen is enlarged, examination of the blood 
should be made for leukaemia and other types of anemia 
which, when definitely established, shall reject. 



73 

24. Abdominal tumors. 

The palpation of a definite abdominal tumor calls 
for a thorough investigation of its nature. 

In paragraph 3, page 59, attention is called to dis- 
tention of the urinary bladder as one of the causes of an 
abdominal tumor. 

When the palpated tumor suggests an appendicitis se n\ c to?amp and 
with abscess or inflammatory exudate, or a distended 
gall-bladder. (See Sec. XIII, 5 and 6, this Manual.) 

If the palpable tumor is in the region of the kidney, 
see genitourinary section, paragraph xv, page 80. 

Abdominal tumors due to enlargement of the liver 
or spleen, or to a supposed cancer of the colon have 
been discussed. 

The clinical diagnosis of the cause and nature of any 
abdominal tumor is always difficult. The number of 
cases of abdominal tumor in men under the age of 31 
years is small. For this reason when the diagnosis is 
doubtful the registrant should be placed in the group of 
temporary defects (sec. 187, S. S. R.), unless the Medical 
Advisory Board is convinced that the tumor is incurable 
or inoperable, when he should be rejected. 

25. Tuberculous peritonitis. 

The objective findings of this lesion are the palpation Reject, 
of an abdominal mass and the demonstration of fluid in 
the peritoneal cavity; as a rule, also, the registrant will 
be under weight and anemic and exhibit fever. Irre- 
spective of the diagnosis, such objective findings are 
causes for rejection. 

26. Tumors of the abdominal wall. 

Those due to irreducible hernia have been discussed. 

The common tumor of the abdominal wall is a fibroma Accept. 
in the area of the recti muscles. Registrants with 
tumors of this kind should be accepted. 

27. Fistula. 

Sinuses in the abdominal wall communicating with 
hollow viscera, whether spontaneous in origin or follow- 
ing operation or injury, should be carefully investigated. 

If in the opinion of the Medical Advisory Board the Doubtful. 
lesion is distinctly operable and curable, the registrant 
should be placed in the deferred remediable group 
(Group B) . When in the opinion of the Medical Advisory 
Board there is a serious question as to its operability or 



74 



curability, the registrant should be rejected or accepted 
for special or special military service. (Group C.) 

Now and then after the drainage for appendicitis a 
deep sinus may persist for months without fecal matter 
exuding through this sinus. In the majority of such 
cases operation is contraindicated. Registrants with 
sinuses of such character should be placed in the group 
or temporary defects. (Sec. 187, S. S. R.). 

XIV. ANUS. 

Regulations for the Local Board. (Section 184 (1), S. S. R.) 

Acceptance. Accept all registrants in which the anus is apparently 
normal and all with small external and internal hemor- 
rhoids, fissures, and condylomata. 

Refer all other cases to the Medical Advisory Board. 

Lesions. Reject no lesions in this area. 

Regulations for the Medical Advisory Board. 
Accept. Accept all registrants with external hemorrhoids and 

with internal hemorrhoids, providing the local condition 
is not interfering with the registrant's ability to work 
and providing an examination reveals no indication for. 
immediate operation. 
diawe ept defe e r?ed Pl ace m the remediable deferred group (Group B), all 
group. cases of internal hemorrhoids which on account of bleeding 

or prolapse are evidently giving discomfort and interfering 
with the work of the registrant. 
diabfe ept defe e r?ed Pl ace m ^ ne remediable deferred group (Group B), with 
group. hemorrhoids and prolapse of the rectum of a degree as 

easily operable as the ordinary case of internal hemorrhoids. 
Reject. Reject from all military service registrants with an 

extreme degree of prolapse of the rectum which in the 
opinion of the Medical Advisory Board are not remediable 
by operation. 
Accept. Place all registrants with a simple fistula in ano in 

the remediable deferred group (Group B), provided 
lesion seems operable. 
Reject. Reject from all military service registrants with irre- 

mideable multiple fistula in ano, especially those which 
have recurred once or more after operation. 

In all cases of registrants with fistula in ano accepted 
for general military service, remember the possibility of 
incipient tuberculosis of the lungs. 
Accept. Accept registrants who claim they have pruritis ani, 

providing the urine shows no sugar. 



75 

Reject registrants from all military service with, paraly- Re J ect - 
sis of the sphincter ani associated with lost control and 
withholding the feces in the lower bowel irrespective of 
the cause. 

' Reject registrants from all military service in which Reject. 
there is a definite and pronounced stricture in the area 
of the anus or lower rectum irrespective of its cause. 

Accept registrants who have been operated upon for Accept, 
any benign lesion in the region of the anus and lower 
rectum, providing they have control of the stool and 
no marked stricture. 

In the examination for lesions in the region of the Examination 

° oi annus. 

anus and lower rectum there must be in every instance 
a rectal examination with the finger and inspection. 
The best position for inspection is the knee chest. In 
this position and during inspection the registrant should 
be requested to bear down. 

When indicated, the lower rectum should be examined Proctoscope. 
with the proctoscope. 

Reject registrants with definite evidence of cancer of Reject, 
the anus or lower rectum, or who bring verified evidence 
that they have been operated on for this lesion, irrespec- 
tive of whether there is local recurrence or not. 



XV. GENITO-URINARY ORGANS AND VENEREAL DISEASES. 

Regulations for the Local Board. (Section 184 (m) S. S. R.) 

Reject extra version of the bladder, distinct hermaph- Rejection. 
rodites, and registrants whose penis has been totally 
destroyed by operation or disease. 

Accept all cases with no signs of disease of the Acceptance. 
genito-urinary organs, all acute and chronic cases 
of gonorrhea and syphilis who have no complica- 
tions permanently incapacitating. 

Accept varicocele, hydrocele, undescended testicle, Acceptance. 
and registrants with but one testicle, providing they do 
not give a definite history that the removed testicle 
was the seat of malignant disease. 

Refer all cases in which the history and examination 
indicate an acute or chronic nephritis, all cases in which 
you find blood in the urine, and all other doubtful cases 
to the Medical Advisory Board. 

Registrants with gonorrhea or syphilis should be ad- Gonorrhea or 

° D ° r mi syphilis to be 

vised to accept treatment pending receipt of orders to treated. 
report for duty. 



Physical exam- 
ination. 



76 

Regulations for the Medical Advisory Board. 

VENEREAL DISEASES. 

Gonorrhea and its complications. 

Registrants temporarily incapacitated with the com- 
plications of gonorrhea, syphilis, or chancroid may be 
- placed in the group of temporary defects, section 187, 
S. S. R., and granted a reasonable delay before completing 
the physical examination. During this time they should 
be urged to take proper treatment. 
ccep ' It is of the utmost importance for the Medical Advi- 

sory Board to distinctly bear in mind that gonorrhea 
in all of its stages does not unfit a registrant for general 
military service. 
ccep ' All the complications of gonorrhea which are remediable 

shall be accepted for general military service. Stricture, 
fistula, abscess, epididymitis, seminal vesiculitis, prosta- 
titis, cystitis, and joint complications, shall be accepted 
if in the judgment of the Medical Advisory Board the 
condition is remediable. If the Medical Advisory Board 
is not in a position to make a thorough investigation with 
the instruments of precision, or if it is in any doubt, the 
registrant shall be accepted for general military service. 
gonorrhea 1611 * of ^ n au ^ ^ ne cantonments provision has been made for 
the segregation and treatment by experts of all regis- 
trants suffering with gonorrhea and its complications. 
Accept. j?oy this reason every registrant suffering with gonor- 

rhea with or without remediable complications should be 
accepted as physically qualified for general military 
service. (Group A.) 

If the registrant can be given proper treatment, this 
can be advised and instituted pending receipt of orders to 
report for duty. 

This treatment should be given only by members of 
the profession specially trained with the modern instru- 
ments of precision, modern methods and who have had 
large experience. 

When the joint complications of gonorrhea have 
reached a stage of distinct ankylosis, the classification 
of the registrant will be made upon the actual resultant 
loss of function as described in Section XVI, and will 
not depend upon the presence or absence of gonorrhoea 
or any other complication. 
Accept. Syphilis and all its remediable complications shall be 

accepted for general military service. The registrant 



77 

should be advised treatment pending receipt of orders 
to report for duty. 

Chancroid and Chancroidal Glands of the Groin shall ccept * 
be accepted for general military service unless in the 
opinion of the Medical Advisory Board it is of a degree 
in which it would be unsafe to order the registrant to a 
cantonment. When this unusual incapacitating com- 
plication is present the registrant shall be considered as 
having a temporary defect, section 187, S. S. R. 

In all cases the registrant shall be advised treatment 
pending receipt of orders to report for duty. 

Registrants with chancroid, healed or unhealed, and 
with infected or enlarged glands in the groin, and who 
consent to operation upon these glands, should not be 
subjected to such operation unless there are definite signs 
of suppuration and the extent of the operation must be 
confined to incision and guarded curetting. It is the 
consensus of opinion among surgeons of experience that 
the complete dissection of the glands in the groin for 
gonorrheal or chancroidal lymphangitis not only pro- 
longs convalescence, but is often followed by lymphatic 
oedema of the penis, scrotum, and leg, in some cases to 
a degree that may be called elephantiasis. 

Registrants with phimosis, even with adherent pre- Acce P*° 
puce, shall be accepted for general military service; 
even though the registrant consents, circumcision should 
not be performed unless it is distinctly indicated. 

Benign warts and other benign tumors of the glans penis Acce pt« 
and the prepuce and the so-called venereal warts, do not 
disqualify the registrant for general military service. 
If the registrant consents, their removal may be per- 
formed pending receipt of orders to report for duty. 

Malignant tumors of the penis. — Registrants with a Doubtful, 
growth or ulcer on the penis suggestive of malignancy 
should not be accepted for general military service. 
When the registrant consents to operation, judgment 
shall be deferred until a microscopic study of the removed 
lesion is made. If the diagnosis is cancer, the registrant 
shall be rejected. If it is not cancer, he shall be ac- 
cepted. When the registrant refuses operation he shall 
be placed in the group of temporary delects, section 187, 
S. S. R., for further observation, unless in the opinion 
of the Medical Advisory Board there is no question that 
the lesion is malignant, and the registrant shall then be 
rejected. 

40712°— 18 6 



78 

When the registrant furnishes a verified history that 
he has been operated on for cancer of the penis he shall 
be rejected if the entire penis has been removed by opera- 
tion. When, however, sufficient of the penis remains 
not to interfere with the function of micturition, or not 
to be an unsightly deformity, the registrant shall be 
accepted, if there are no signs of recurrence and it is 
three years since the operation. Otherwise he shall be 
be rejected. 

In cases of this kind try to get the microscopic sec- 
tion of the original tumor and submit it to two or 
more pathologists for reexamination, because not infre- 
quently in young men the so-called malignant venereal 
wart has been removed under the diagnosis of cancer. 
Such warts are rarely, if ever, carcinoma. When the re- 
examination of such a section changes the diagnosis 
from cancer to that of a benign wart, the registrant shall 
be accepted for general military service. 

Accept. Varicocele. — The physicians on the Local Board have 

been directed to accept registrants with varicoceles. 
Should cases of this kind be referred to the Medical 
Advisory Boards because of the large size of the vari- 
cocele, or because the registrant claims that he is inca- 
pacitated, the registrant shall be accepted for general 
military service, and operation shall only be advised 
pending receipt of orders to report for duty when in the 
judgment of the Medical Advisory Board it is distinctly 
indicated on account of the large size of the varicocele. 
Do not advise operation to relieve the patient of nervous 
symptoms which he may attribute to his varicocele. 

Accept. Hydrocele. — Should registrants with large hydroceles 

be referred to the Medical Advisory Board, and when in 
its opinion operation is indicated because of its large size, 
the registrant may have this operation performed pend- 
ing receipt of orders to report for duty; but hydrocele 
itself is not a cause for rejection. 

Accept. Testicle. — The absence of one testicle is not a cause for 

rejection unless the registrant furnishes verified proof 
that the testicle was removed for malignant disease, and 
he should then be rejected. If possible, in cases of this 
kind, sections of the removed tumor should be obtained 
and submitted to two or more pathologists to verify the 
diagnosis. 

Atrophy of one testicle does not disqualify for general 
military service. 



79 

Atrophy or loss of both testicles does not disqualify 
for general military service if the registrant is otherwise 
physically and mentally fit. 

When there is enlargement of the testicle, apparently 
not due to hydrocele nor to gumma, the possibility 
of malignant tumor must be considered. The regis- 
trant should be placed in the deferred remediable group. 
(Group B). 

In all cases of testicular enlargement, with or without 
hydrocele, make the Wassermann test. If positive, ad- 
vise salvarsan. 

Epididymitis. — This lesion, acute or chronic, is usually Acce P t - 
associated with gonorrhea. It may be a temporary 
result after operation for varicocele or inguinal hernia. 
The lesion itself does not disqualify. 

A registrant with a chronic induration of the epididy- 
mis with no history or evidence of gonorrhea, no history 
of recent mumps, or recent operation for hernia or vari- 
cocele, should be examined with the greatest care for 
other signs of tuberculosis of the genito-urinary tract 
and tuberculosis elsewhere. 

Tuberculosis of the genito-urinary tract disqualifies for Reject. 
all military service. 

A registrant with such an induration of the epidi- 
dymis and without evidence of tuberculosis elsewhere 
should be advised to have the area explored under 
novocaine — an operation which is the best thing for him. 
The indurated area should be removed and a microscopic 
section made. If tuberculosis is found, the registrant 
shall be disqualified for any military service. 

When the registrant refuses this operation and is other- 
wise physically qualified, he shall be accepted for general 
military service. 

Tuberculosis of the Genito- Urinary Organs. — In the Reject, 
majority of cases there will be a single or bilateral epi- 
didymitis, with or without abscess or sinus, small nodules 
along the vas defenrens, induration of the seminal vesi- 
cles and prostate, and a purulent cystitis. A registrant 
with such objective signs shall be rejected, even though 
the examination of the urine fails to reveal the tubercle 
bacilli. 

Cystitis. — Registrants with recent or acute cystitis 
should be held as temporary defect, section 187, S. S. R. 

Registrants with chronic or subacute cystitis without 
residual urine shall be accepted for general military 



80 

service and advised treatment by a competent urologils 
pending receipt of orders to report for duty. 

Registrants with chronic cystitis with definite residual 
urine of a duration longer than two months, in which 
there is no evidence of stricture of urethra, should be 
carefully studied as to the cause, such as diseases of 
the central nervous system, obstruction at the neck of 
the bladder, and stone. If there is no stone in tin blad- 
der and no other remediable cause to be demonstrated, 
the registrant shall be rejected. 

If a vesical calcucus is found, the registrant should be 
placed in deferred remediable group (Group B) . 
Reject. Bladder Tumors. — Registrants who show at the cysto- 

scopic examination benign or malignant tumors of the 
bladder or who give a history of operation for a malig- 
nant tumor of the bladder shall be rejected. 

Registrants who give a history of the removal of a 
benign tumor of the bladder shall be accepted for general 
military service only when a cystoscopic examination 
shows no evidence of a recurrence of the tumor. 

If the Medical Advisory Board is not prepared to per- 
form cystoscopic examinations, and the concomitant 
cystitis is not of a degree to disqualify, the registrant 
should be accepted. 

Kidney, pyelitis. — This is diagnosed only when the 
ureters are catheterized and the pus demonstrated to 
come from the kidney and not from the bladder. 

Registrants with pyelitis and no evidence of any other 
serious condition of the kidney should be placed in the 
deferred remediable group (Group B). 

Severe infections of the kidney, surgical kidney, 
whether associated with renal calculus or not, tubercu- 
losis of the kidney, extreme degrees of hydronephrosis 
and all tumors of the kidney — that is, lesions for which 
the remedy is nephrectomy — and all registrants who 
have had one kidney removed or destroyed by any cause, 
should be rejected. 

Renal Calculus. — When symptoms suggest and the 
X-ray shows a stone in the kidney and there are no 
definite objective findings of a serious injury to the 
kidney, the registrant shall be placed in the deferred 
remediable group (Group B). 

Palpable or floating kidney is not of itself a cause for 
rejection. 



81 

Albumen and casts, with or without blood in the urine, Albuminuria. 
found on repeated examination, should place the regis- 
trant in the group of temporary defects, Section 187, 
S. S. R. Chronic nephritis disqualifies for any military 
service, while acute transitory nephritis does not dis- 
qualify after all the symptoms have disappeared and 
repeated examinations of the urine are negative* 

Transient albuminuria does not of itself disqualify for 
general military service, but these cases should be care- 
fully studied, and examination temporarily delayed, sec- 
tion 187, S. S. R. 

Persistent permanent albuminuria which does not dis- 
appear when the patient is at rest and on restricted diet, 
shall be rejected. 

Stone in the ureter without complications should be 
placed in the deferred remediable group (Group B) . 

XVI. AFFECTIONS COMMON TO BOTH EXTREMITIES. 

Regulations for Local Board. (Section 184 (n), S. S. R.) 

Reject all diseases, injuries, and amputations which Rejection, 
have destroyed the function of both lower limbs or both 
upper limbs. 

Reject all registrants with an extensive disease of one 
joint associated with sinuses of long duration. 

Accept all registrants who have no loss of function of 
both upper and lower extremities and no restriction of 
joint function. 

Refer to the Medical Advisory Board all registrants 
with one good arm and one good lower extremity and all 
other doubtful cases. 

Regulations for the Medical Advisory Board. 

Accept for limited and special military service (Group 
C) registrants with one good arm and one good lower ex- 
tremity providing he is able to perform and is performing 
some useful occupation; if not, reject (Group D). 



Rejection. 
Acceptance. 



GENERAL STATEMENTS IN REGARD TO AFFECTIONS OF 

BONES AND JOINTS. 

Proven active tuberculosis of bone or joint shall reject the 
registrant from any military service. 

The diagnosis of active tuberculosis of bone or joint 
shall rest upon the examination showing swelling, re- 



82 

striction of joint motion, tenderness and muscle spasm, 
and the evidence of bone destruction in the X-ray plate. 

If the registrant gives a history of tuberculosis of bone 
or joint apparently healed with no evidence of active 
disease for at least 10 years, the acceptance of this regis- 
trant for general military service or for special or limited 
service shall depend upon the degree of loss of function 
in the involved joint and degree of deformity and 
disability. 

If the period is less than 10 years the registrant shall be 
rejected. 

Registrant suffering from a recent injury of bone or 
joint, with or without fracture or dislocation, shall be 
given a reasonable time for recovery before the final 
examination is made. Registrants confined to their house 
or the hospital or under ambulatory treatment for non- 
tuberculous osteomyelitis or for any form of nontuber- 
culous arthritis of one or more joints will be given a 
sreasonable time for convalescence for their final exami- 
nation. Temporary defect, section 187, S. S. R. 

NONTUBERCULOUS AFFECTIONS OF BONES AND JOINTS. 

The decision as to acceptance or rejection for general 
or for special or limited military service for affections of 
the bones and joints of nontiiberculous character shall 
depend upon the function of the involved portion of the 
extremity at the time of the examination and the presence 
or absence of a sinus or other distinct evidence of the ex- 
istence of a still active process, and not upon the cause 
or nature of the previous disease. 

Registrants giving a history of a compound fracture 
and who on examination reveal a sinus communicating 
with the seat of the fracture when the union is solid and 
function is good shall be accepted. 

Registrants who give a history of a fracture which has 
been operated upon and fixed by a bone plate with screws 
shall be accepted if the bone union is solid, and the 
function is unimpaired. 

Registrants presenting ununited fractures shall be 
placed in the Deferred Remedial Group (Group B), if in 
the opinion of the Medical Advisory Board the nonunion 
is remediable. If in the opinion of the Medical Ad- 
visory Board the condition is irremediable by operation 
or by treatment, they should be accepted for special or 



83 

limited military service (Group C), unless it is the opin- 
ion of the Medical Advisory Board that they should be 
rejected. 

Registrants who give a history of osteomyelitis and 
who on examination show evidence of this process appar- 
ently healed, but who have still one or more existing 
sinuses, shall be rejected for general military service or 
accepted for limited or special military service, according 
to the degree of the disability. 

Accept as physically qualified for general military Accept. 
service registrants with bone tumors which do not inter- 
fere with joint function or in any way with the function 
of the extremity. 

Bone tumors belonging to this class are single and 
multiple exostoses and healed benign bone cysts. 

Accept as physically qualified for general military Accept. 
service registrants who give a history of an operation 
for a benign bone tumor and the function of whose ex- 
tremity has not been impaired by this operation. 

Bone tumors belonging to this class are exostoses, 
enchondroma, benign bone cysts, and the giant cell tumor. 

Place in the deferred remediable group (Group B), 
registrants in which the examination and X-ray picture 
suggests a benign bone tumor remediable by operation 
without loss of function of the neighboring joint or the 
extremity. 

Reject as physically deficient and not physically quali- Reject, 
fied for military service registrants who bring authentic 
data of an operation for a malignant bone tumor, irre- 
spective of the result, and registrants in which the diag- 
nosis from physical examination and X ray suggests a 
large probability of a malignant bone tumor. 

Accept as physically qualified for special or limited mili- Acce P t 
tary service (Group C) , registrants who give a history of 
an operation for some benign bone tumor but the result of 
which operation has interfered with the function of the 
neighboring joint or the function of the extremity in- 
volved of a degree rendering the registrant unfit for gen- 
eral military service. 

The so-called giant cell sarcoma shall be looked upon 
in these regulations as a benign bone tumor, provided 
the Medical Advisory Board is able to submit sections of 
the tumor to two competent pathologists who agree in 
the diagnosis of a benign bone tumor. 



84 

Traumatism, with and without fracture, and syphilis 
may give rise to an ossifying periosteal new growth 
which might be incorrectly diagnosed periosteal sar- 
coma. Cases of this kind should be studied with the 
X ray, the Wasserman test taken, and salvarsan em- 
ployed as a therapeutic test. 

A lesion of this kind rarely if ever interferes with 
function, and if sarcoma can be excluded the registrant 
should be accepted for general military service (Group A) . 

This form of benign, ossifying, periostitis is quite 
frequent, and the incorrect diagnosis of periosteal sar- 
coma has been made in a number of cases of this kind. 
For this reason the Medical Advisory Board is urged to 
examine these cases with the greatest care and defer 
judgment, placing the registrant temporarily in the 
group of temporary defects, section 187, S. S. R. 

XVH. UPPER EXTREMITIES. 

Registrants who have restriction of motion in one 
joint of the upper extremities — shoulder, elbow, or wrist — 
with no evidence of active disease of bone or joint, pro- 
vided they present good function and weight-bearing 
power, shall be accepted for general military service 
when the limitation of active motion is not more than 25 
per cent of the normal. If the restriction of motion is more 
than 25 per cent of normal, or when two or more joints 
are involved, irrespective of the degree of limitation, the 
registrants shall be accepted for special or limited military 
service (Group C), providing the Medical Advisory Board 
is of the opinion, after investigation, that they are 
capable of any service. If not, they should be rejected. 

Disease of bone, healed, with some resulting deformity, 
shall be accepted in accordance with the degree of the 
restriction of the joint as above noted (25 per cent of 
normal motion). Muscle paralysis or contracture of 
tendon or nerves shall be accepted on the same basis, 
namely, in accordance to the degree of the restriction of 
the joint motion (25 per cent of the normal joint motion). 

Regulations for the Local Board. (Section 184(o), S. S. R.) 

Acceptance, Hands. — Accept all registrants whose function of 

the wrist and fingers is not permanently impaired and 
who have not lost either a thumb or the index finger 
on the right hand, or two fingers on one hand. 

Refer all other and doubtful cases to the Medical 
Advisory Board. 



85 



Regulations for the Medical Advisory Board. 

Hands. — Registrants with defects or deformities of the Gr ^ u c p c c p t foT 
hands not described in the regulations of the local board 
as within the standards of unconditional acceptance may 
be accepted for special or limited military service by the 
Medical Advisory Board with the following defects or 
deformities : 

Loss of thumb and index finger. 

Loss of two fingers on one hand. 

Webbed fingers. 

One or more partially stiff fingers, with or without 
contractures. 

Total loss of fingers of one hand. 

Deformities or defects from injury or disease. 

Reject no registrant with disabling deformities of the 
hand or fingers, when in his present civil occupation he 
is able to pursue any occupation which would be useful 
in any occupation in special or limited military service. 
(Group C). 

Accept for general military service (Group A), regis- 
trants with ganglion and other benign tumors of the hand 
or fingers. 

XVin. LOWER EXTREMITIES. 

Regulations for Local Board. (Section 184(p), S. S. R.) 

Accept all registrants with movable joints and no Acce P t - 
deformity which interferes with walking and weight- 
bearing power. 

Accept registrants with varicose veins when not asso- 
ciated with edema and leg ulcer. 

Accept all foot and ankle lesions if they do not inter- 
fere with the wearing of an ordinary shoe and with 
walking and weight-bearing power; hammer toe, hallux 
valgus, bunion, callosities, the different types of 'flat, 
club, and claw foot are to be accepted if they come 
within the above requirements. 

Refer all doubtful and other cases to the Medical 
Advisory Board. 

Reject no foot cases. 

Regulations for the Medical Advisory Board. 

Registrants who have restriction of motion of one joint 
of the lower extremities, hip, knee, or ankle, with no 
evidence of active disease of the bone or joint, shall be 
accepted for general military service when the limitation 



Accept. 



Accept. 



Foot cases. 



86 



Accept. 



Accept. 



of active motion is not more than 25 per cent of the 
normal. If the restriction of the motion is more than 25 
per cent of the normal or when two or more joints are 
involved, irrespective of the degree of limitation, the regis- 
trant shall be accepted for special or limited military 
service (Group C), provided the Medical Advisory Board 
is of the opinion (after investigation) that they are capa- 
ble of any service; if not, they shall be rejected. 

Accept registrants for general military service with 
such deformities as slight coxavara, knock knee, bow leg, 
and deformity of the ankle after Potts fracture, pro- 
vided there is no interference to the function of walking 
and weight bearing, as demonstrated by the examina- 
tion and by the occupation in which the registrant is 
engaged at the time of examination. 

Knee joint (so-called internal derangements of the 
knee). — Loose bodies, dislocation of semilunar, slipping 
patella, place in the deferred remediable group (Group B). 

Busitis. — Kegistrants with benign tumors, extra artic- 
ular, shall be accepted for general military service when 
not disabling. In the latter case place in the deferred 
remediable group (Group B). 

Foot. — Accept for general military service all regis- 
trants with lesion of the feet and toes irrespective of pres- 
ent function, when, after examination it is of the opinion 
of the Medical Advisory Board that the lesion is remedi- 
able by treatment or by operation. If no member of 
the Medical Advisory Board is trained in orthopedic 
surgery the board shall accept all doubtful cases. Regis- 
trants with lesions or deformities of the foot totally dis- 
abling them for general military service, and, in the 
opinion of the Medical Advisory Board, irremediable by 
treatment or by operation, should be accepted for special 
or limited military service (Group C), or rejected on the 
basis of the examination taken in conjunction with the 
registrant's present occupation. 

Limping and lameness, per se, are not a cause for re- 
jection. The cause thereof must be the deciding factor. 

Registrants presenting a shortening of the lower ex- 
tremity of 1 inch or less is not, per se, a cause for rejec- 
tion. Registrants presenting shortening of the lower 
extremity of more than 1 inch may be accepted and 
placed in Group C for special or limited military service. 



87 

XIX. HEIGHT, WEIGHT, AND CHEST MEASUREMENTS. 
Regulations for the Local Board. (Section 184 (q) S. S. R.) 

Registrants whose chest measurements do not come 
within the limits of the table and who have no disqualify- 
ing defect are referred to the Medical Advisory Board. 

Accept registrants above 78 inches in height when ex- 78 j^l above 
ceptionally well proportioned. Refer all other such cases 
to the Medical Advisory Board. 

Reject registrants of less than 58 inches in height. 58inches. ess m 

Refer to the Medical Advisory Board registrants whose 
height is more than 58 inches and less than 60. 

Reject registrants whose weight is less than 100 pounds 100 po 6 un(£ s ^ 
unless it is plainly due to some recent illness and other- 
wise the registrants have no disqualifying defect. 

Registrants whose weight is more than 100 pounds and 
less than 114 pounds and who have no other disqualifying 
defect are to be referred to the Medical Advisory Board. 

Registrants under weight in proportion to their height f 7ne^itr ei8h * 
(see table), unless it is plainly due to some temporary 
cause, are referred to the Medical Advisory Board. When 
this underweight can reasonably be explained and the 
registrant otherwise is physically fit, accept. 

Registrants with overweight are to be accepted unless he ? g ^ rweight for 
the obesity interferes with normal physical activity. Re- 
fer all doubtful cases to the Medical Advisory Board. 

The following weights and measurements should be 
taken with the greatest care: 



A. 
Standard accepted measurements. 


B. 

The following variations from the standard shown 
in column A are permissible when the applicant 
is active, has firm muscles, and is evidently vig- 
orous and healthy. 




Weight. 


Chest measurement. 


Height. 


Weight. 


Chest measurement. 


Height. 


At ex- 
piration. 


Mobility. 


At ex- 
piration. 


Mobility. 


Inches. 
60 


Pounds. 
120 
120 
120 
124 
128 
130 
132 
134 
141 
148 
155 
162 
169 
176 
183 
190 
197 
204 
211 


Inches. 
31 
31 
31 
31 
32 
32 
32J 
33 
33i 
33§ 
34 
34i 
34f 

351; 

36»- 
36f 
37| 
37| 
38J 


Inches. 
2 
2 
2 
2 
2 
2 
2 
2 
2§ 
2£ 
2| 
2£ 
3 
3 
3 

H 
H 

4 


Inches. 
60 


Pounds. 
114 
114 
114 
116 
120 
120 
120 
120 
121 
124 
128 
133 
138 
143 
148 
155 
161 
168 
175 


Inches. 
30 
30 
30 
30 
30 
30 
30i 
30£ 
30f 
31 
31i 
31f 
32i 
32f 
33J 
34i 
34$ 
35f 
351 


Inches. 

2 


61 


61 


2 


62 


62 


2 


63 


63 


2 


64 


64.. 


2 


65 


65 


2 


66 


66 . 


2 


67 


67 . 


2 


68 


68.. 


2 


69 : 


69 


2 


70 


70 


2 


71 


71.. 


2 


72 


72.. . 


2* 


73 '. 


73 


74 


74 


75 


75.. 


76 


76 


24 


77 


77 . 


3 


78 


78 . 


3 









88 

Regulations for the Medical Advisory Board. 

Directions for talcing height. — Use a board at least 2 
inches wide by 80 inches long, placed vertically, and 
carefully graduated to I inch, between 60 inches and 78 
inches from floor. Obtain height by placing vertically 
in firm contact with the top of head and against the 
measuring rod an accurately squared board about 6 by 6 
by 2 inches — best permanently attached to graduated 
board, by long cord. The recruit should stand erect 
with back to the graduated board, eyes straight to the 
front. 
Reject. Registrants whose height is less than 60 inches shall 

be rejected from general military service, but if they are 
Accept. otherwise physically and mentally fit they may be ac- 

cepted for special or limited military service. 

Registrants who weigh less than 114 pounds shall not 
be accepted for general military service unless in the 
opinion of the Medical Advisory Board it is a remediable 
defect. 

Registrants who weigh more than 120 pounds, but less 
than the prescribed weight for the height indicated in the 
table of measurements of height and weight, may be ac- 
cepted when in the opinion of the Advisory Board the 
defect is remediable by camp life. If, however, in the 
opinion of the Advisory Board the defect is not remedi- 
able these registrants, if otherwise physically and men- 
tally fit, shall be accepted for special and limited military 
service. (Group C.) 

A registrant who appears not to be able to expand the 
chest 2, 2\ y or 3 inches, respectively, as per table should 
be examined especially to ascertain if the failure of 
adequate chest expansion is due to ignorance and lack 
of practice. If in the opinion of the Advisory Board 
the lack of the prescribed expansion is remediable by 
camp fife and the registrant is otherwise physically and 
mentally fit he shall be accepted. If, however, in the 
opinion of the Advisory Board the defect of expansion 
is not remediable and the registrant is otherwise phys- 
ically and mentally fit he shall be accepted for special 
and limited military service. (Group C.) 

A registrant whose height is 78 inches or more should 
be carefully studied. If he is well proportioned and not 
over or under weight and otherwise physically fit with 
no signs of giantism or acromeglia he should be accepted. 



89 

XX. DENTAL REQUIREMENTS. 

Regulations for the Local Board. (Section 185, S. S. R.) 

Accept registrants who have three serviceable natural Acceptance, 
masticating teeth above and three below opposing and 
three serviceable natural incisors above and three below 
opposing. All these teeth must be so opposed as to serve 
the purpose of incision and mastication. Therefore, the 
registrant shall have a minimum total of six masticating 
teeth and a minimum total of six incisor teeth. 

The needed dental treatment will be performed at the Dental treat- 
cantonment. However, if time permits, a registrant, if 
he prefers, may have the necessary work done at home . 
previous to his induction into military service. 

DEFINITIONS. 

(a) The term "masticating teeth" includes molar and Masticating 
bicuspid teeth, and the term " incisors " includes incisor 

and cuspid teeth. 

(b) A natural tooth which is carious (one with a Natural 
cavity), which can be restored by filling, is to be consid- 
ered as a natural serviceable tooth. 

(c) Teeth which are restored by crowns or dummies Bridge work. 
attached to fixed bridge work, when well placed, shall be 
considered as serviceable natural teeth, when the history 

and the appearance of these teeth is such as to clearly Physical ex- 

* . amination. 

warrant such assumption. 

(d) A tooth is not to be considered a serviceable infected 

teeth. 

natural tooth when it is involved with excessively deep 
pyorrhea pockets, or when its root end is involved with a 
known infection that has or has not an evacuating sinus 
discharging through the mucous membrane or skin. 
Refer all other cases to the Medical Advisory Board. 

No registrants can be rejected on account of 
teeth defects. (C. S. S. R. No. 3, Jan. 28, 1918.) 

Regulations for Medical Advisory Board. 

The dentist on the Medical Advisory Board shall 
reexamine the teeth of all registrants referred by the 
Local Board. 

When this examination demonstrates that the regis- 
trant has the number and character of teeth placing 
him within the standards of unconditional acceptance 
as clearly defined in the regulations to the Local Board, 
section 185, S. S. R., the registrant shall be accepted 
for general military service. 



90 

All other registrants who do not come within the stan- 
dards of unconditional acceptance of dental require- 
ments shall be accepted for special or limited military 
service (Group C). 

URGENT SUGGESTION FOR THE BENEFIT OF REGISTRANTS 
ACCEPTED FOR GENERAL MILITARY SERVICE. 

The dentist on the Medical Advisory Board is urged 
to consult and cooperate with the dentist on the Local 
Board to devise ways and means of persuading regis- 
trants accepted for general military service to have 
urgent dental work done pending receipt of orders to 
report for duty. 

All hopelessly diseased teeth should be extracted. 
Chronic focal infections involving the teeth and jaws 
should be eradicated. If this is done before the regis- 
trant reports for duty at the cantonment, the necessary 
plate work can be more quickly placed at the canton- 
ment, and even more important the registrant will be 
protected from systemic complications which are liable 
to occur when the individual is placed under the strain 
of military training. 

XXI. GENERAL. 

Regulations for the Local Board. (Section 184 (r), S. S. R.) 

Tuberculosis. Refer to the Medical Advisory Board all registrants 

Physical exam- who, from their history and after their complete exami- 
nation. . ., .,. „ , , . 

nation, suggest the possibility 01 tuberculosis in some 

part of the body. 

Anemia. Refer to the Medical Advisory Board all cases who, 

at the general examination, seem to have a marked 
anemia even though otherwise physically fit. 

Debility. Refer to the Medical Advisory Board all cases who, 

after examination, impress you as in an extreme state of 
debility, even if the other examinations are negative. 

Tumor. Refer to the Medical Advisory Board all registrants 

who give a history of an operation or any other treat- 
ment for a malignant tumor, even if there is no evidence 
of recurrence, and all registrants who, at examination, 
have any tumor or ulcer suspicious of malignancy. 
incapa^t e a 3 ted and Registrants confined to their homes, hospitals, or insti- 
tutions who claim to be suffering from hopeless totally 
incapacitating diseases should be thoroughly investi- 
gated by the Local Board in consultation, if necessary, 
with the Medical Advisory Board. 



91 

Some of these registrants may have remediable defects. 
In others the claim may be incorrect. (G. S. S. R. No. 3, 
Jan. 28, 1918.) 
Regulations for the Medical Advisory Board. 

The registrant who upon examination is found to suffer Anemia. 
from anemia should be examined carefully to ascertain 
the cause if that is possible. If the anemia is remediable 
by removal of a cause (hemorrhoids, intestinal parasites, 
etc.) or by treatment or by the salutary effects of camp 
life, he should be accepted for general military service. 
If the anemia is not remediable and is a cause of general 
debility, he should be rejected. 

The registrant who on examination is found to suffer r>ebmty. 
from a general debility evidenced by lethargy and flabby 
muscles should be further examined for tuberculosis and 
other debility-producing conditions. If in the opinion 
of the Advisory Board the debility is due to a remediable 
condition but not to tuberculosis by treatment and camp 
life and he is otherwise physically and mentally fit he 
shall be accepted for general military service. 

Registrants confined to their homes, hospitals, and in- 
stitutions for the care of the sick who claim to suffer from 
totally incapacitating diseases should be investigated by 
the Advisory Board as consultants to the Local Boards. 

XXII. NOTES ON MALINGERING. 

Malingerers may be divided into three general groups — 

(1) Real malingerers with nothing the matter with 
them, who injure themselves, or make allegations respect- 
ing diseases or such conditions as drug taking, or who 
counterfeit disease with full consciousness and responsi- 
bility; all for the purpose of evading military service. 
Many of these have been coached. A small but important 
group. 

(2) Psychoneurotics, who are natural complainers and 
try to get out of every disagreeable thing in life. Perhaps 
only partially conscious of the nature of the seriousness of 
what they do and only partly responsible. In many the 
motives are not persistent and many can be made into 
good soldiers. 

(3) Confirmed psychoneurotics with long history of 
nervous breakdowns and illnesses who behave like class 
(2) but more persistently, and from whom not much can 
be expected in the way of reconstruction. The important 
question to decide concerning groups (2) and (3) is not one 



92 

of responsibility, but as to whether there is probability of 
the man being turned into a good soldier. 

CAUSES AND MOTIVES OF MALINGERING. 

These must be clearly understood in order that medical 
examiners may be on the alert for deception. The 
foreign born, and especially Jews, are more apt to malinger 
than the native born; eastern Europeans more than 
western Europeans. There are two main types, country 
and city. The country types are foolish and clumsy, 
often grotesque, come for examination provided with 
recently purchased apparatus, such as spectacles, 
ciutches, trusses, etc., complain of pain in the back, 
Kidney trouble, and, in fact, all the diseases which 
are tho subjects of quack advertisements. The city 
types are familiar with the jargon of city clinics, and 
make their complaints less specific. All malingerers are 
generally timid, which makes them fearful of entering 
the Army. Mercenary motives can be traced in many, 
for men hate to give up good jobs. Farmers are disin- 
clined to give up agriculture for military duty, and all 
persons whose lives have created no sense of nationalism 
wish service. But the largest number of malingerers 
are recruited from classes who take the same attitude 
about military service as they take with everything in 
life which requires orderliness, obedience, and industry, 
such as truants, vagrants, wife deserters, etc. Some are 
induced to malinger for the reason that they have friends 
or relatives in the armies of the central powers. Practi- 
cally the only motive that comes to the attention of ad- 
visory boards is to evade service. Few drafted men ma- 
linger for the purpose of obtaining service. 

GENERAL DETECTION. 

The surest means of detecting malingering is a thorough 
understanding by the examiner of the types of people 
who actually do it — and the way they behave. It is 
only in the feigned diseases of the eye and ear that special 
tests are required. Observation in hospital is necessary 
in difficult cases. The vast bulk of malingerers are those 
who exaggerate some actual defect, and the problem for 
the medical examiner is to decide whether the defect 
complained of is sufficient cause for rejection for service. 
Persons of intelligence and education have more difficulty 
in deceiving, as they are bound to express themselves 



93 

freely. If they are reticent in these matters they arouse 
suspicion by their reticence. Those who talk freely may 
be counted on to say things at variance with the existence 
of the disease of which they complain. 

Even if the suspicion of the examiner is aroused at the 
outset his attitude should be that of a physician rather 
than of a court officer. He should obtain information 
regarding the recruit's family relationships, his progress 
at school, his industrial career, truancy, reasons for 
choice of career, earning power, domestic relations. It 
is important to find out the man's views concerning his 
own health. Many boys now in the draft have been 
fed up on quack advertisements, have been coddled at 
home and led to believe that they were delicate, have 
been treated for months or years by unscrupulous 
physicians for diseases which they did not have and 
really have come to believe that they can not stand the 
strain of military service. Explanation in these matters 
is often sufficient for a recruit to abandon his claim of 
illness and to proceed to his duty with cheerfulness. In 
other cases brusque statements that the defect com- 
plained of is not, under any circumstances, a disquali- 
fication brings a prompt change of attitude. Sugges- 
tions of anaesthetics for diagnostic purposes, operations, 
etc., often cause candidate to abandon his claims. 
Throughout, the attention of the person under exami- 
nation is to be distracted so that while he is being exam- 
ined for one thing, he believes he is being examined for 
something else. 

DISTURBANCES OF VISION AND HEARING. 

(See Pars. VII and VIII.) 

General medical. — Among the general medical con- 
ditions which must be considered under the heading of 
malingering are indefinite illnesses which clear up rapidly 
under hospital treatment. Sore throat, general pains, 
general disability, and the like fall naturally into this 
class. Cardiac conditions are frequently complained of, 
chiefly as shortness of breath, feelings of suffocation, 
palpitation, suffocating attacks, pain around the heart. 
Tuberculosis is claimed more frequently than other 
pulmonary conditions. Gastric troubles are frequently 

complained of and are usually fortified with a long 
history of " stomach trouble" usually backed up with 

40712°— 18 7 



94 

statements to prove how long and how unsuccessfully 
the patients have been treated for the complaint. Some- 
times a history of gastric ulcer is given in detail. Ab- 
dominal conditions refer chiefly to pain associated with 
adhesions due to old operative conditions. Acute 
appendicitis has been feigned in a number of instances. 

DETECTION AND MANAGEMENT. 

The detection and management of medical cases de- 
pends upon the absence of positive findings in one who 
presents the general characteristics of the malingerer. 
There is especial need for the physical examination to be 
thorough in this group. Some of the cardiac cases at 
first regarded as malingerers were pronounced later by 
the cardiovascular board to have mitral stenosis, and 
similarly proper tests have shown the existence of gastric- 
ulcer in cases which were under suspicion of fraud. The 
estimation of the reality of rheumatic pains is always a 
difficult matter. Proposal of operation has often proved 
a valuable aid in the clearing up of members of this 
group, many men after refusing it having gone meekly 
back to duty in apparently good health. 

General Surgical. — Under this general heading are 
included various surgical conditions, old scars, and in- 
juries of the bones, fractures, and orthopedic conditions. 
The following distribution of diagnoses, from a base hos- 
pital surgical service, is characteristic. Numbers of the 
patients are reported as remaining, on the surgical service 
many days refusing operation, as is to be expected of the 
malingerer. 

Gunshot wound, possibly inflicted with object of discharge from 
service, 4 cases. 

Chopped fingers, possibly inflicted with object of discharge from 
service, 2 cases. 

Amputated fingers (hand lain on railway track), with object of dis- 
charge from service, 1 case. 

Medical (pain in stomach simulating ulcer), with object of discharge 
from service, 4 cases. 

Medical (pain over gall bladder or indefinite!, with object of discharge 
from service, 6 cases. 

Rheumatism, multiple or single arthritis, with object of discharge 
from service, 20 cases. 

Painful operation scars, with object of discharge from service. 3 eases. 

Post-operative adhesions, with object of discharge from service. 10 
cases. 

Varicocele, with object of discharge from service, 20 cases. 

Hernia, mostly inguinal, with object of discharge from service, 20 
cases. 



95 

Hernia, post operative, with object of discharge from service, 4 cases. 

Flat feet, with object of discharge from service, 60 cases. 

Old fractures of legs, feet, and arm3, with object of discharge from 
sendee, 15 cases. 

Multiple small painless lipomata, with object of discharge from serv- 
ice, 1 case. 

Backache, with object of discharge from sendee, 20 cases. 

Infected foot (mild cases refusing operation), with object of discharge 
from service, 2 cases. 

As indicated in the above table, flat feet are among the 
most frequent complaints of this class. These are ex- 
tremely troublesome cases. Many men get discharged 
for this disability, and in the absence of pronounced 
abnormalities it is very difficult to determine that they 
axe malingerers. It should be remembered that many 
men, such as guides and some races hare flat feet and still 
can walk long distance without pain. Stiff joints are 
frequently complained of, usually as having taken their 
origin from a fracture or other injury sustained a long 
time previously, In the absence of palpable signs of 
joint injury and with negative X-ray findings the mo- 
bility of these joints can generally be demonstrated. 

Artificially created conditions. — Men shoot or 
cut off their ringers or toes, practically always on the 
right side, to get disqualified from service. Sometimes 
they put their hands under cars for this purpose. Many 
men have their teeth pulled out. Retention of urine is 
simulated. Egg albumen is injected into the bladder 
or put in urine. Glucose is added to urine. Digitalis, 
thyroid gland preparations, and strophanthus are taken 
to cause disturbance of the heart and cantharides to 
cause albuminuria, The skin is irritated by various irri- 
tating substances which are also injected under it to cre- 
ate abscesses. Various substances are taken to bring 
about purging. An appearance of haemoptosis may be 
produced by adding blood, either human or that of ani- 
mals, to the sputa. Sometimes merely coloring matter is 
added. Those who can vomit voluntarily, what they 
swallow, use the same means to create the appearance of 
haematemesis. Similarly coloring matters can be added 
to the stools. Mechanical and chemical irritations are 
made use of to cause inflammation about practically 
all the body orifices. Jaundice is produced by taking 
picric acid, and crutches, spectacles, trusses, strappings, 
etc., are made use of to create the appearance of disa- 
bility. 



96 

Detection. — Wounds are rarely self-inflicted when wit- 
nesses are present, consequently it is almost impossible 
to be certain of the motive behind these. The artificial 
jaundice is to be recognized by the demonstration of 
picric acid in the urine. 

Bed wetting. — A frequent complaint among candi- 
dates for military service but not a cause for rejection. 

NERVOUS AND MENTAL. 

Insanity. — Karely feigned by recruits and then of 
extremely silly, foolish type. In cases of doubt, hospital 
observation is necessary and verified past records. 
Mental defects frequently feigned, especially by illiterates 
and the foreign tongued. These should be accepted. 
Organic diseases of the central nervous system can not 
be simulated. 

Pain and hyper aesthesia. — The most frequent of 
all complaints. History inconsistent, ordinary traces of 
suffering absent. Absence of other symptoms usually 
accompanying types of pain complained of. Absence of 
painful localized pains. Note behavior of patient when 
unobserved. 

Anaesthesia. — Not a cause of rejection. Complaint 
of anaesthesia itself creates a suspicion of malingering, 
as most patients with anaesthesia are ignorant of it. 
Human pincushions do not always jump when taken 
off their guard. 

Epilepsy. — Men who have sustained head injury are 
very apt to claim fits. These complaints may be in 
reference to grand mal or petit mal. Petit mal attacks 
are spoken of as fainting attacks. In grand mal attacks 
there is loss of pupil response to light, knee jerks are 
lost and the Babinsky reflex may be present. Get 
verified histories. 

Hysteria. — Not feigned in itself, but its existence cre- 
ates confusion as to malingering. The question to be 
decided is whether the recruit is too seriously affected 
with the neurosis to be useful as a soldier. Often, even 
when the physical symptoms are nios<b pronounced (pa- 
ralysis), cure is still possible. 

These registrants should be accepted for general mili- 
tary service. 

The ordinary stigmata of hysteria should not of them- 
selves be causes for rejection. 



97 

Stiff backs. — Stiff backs have been a frequent symp- 
tom of hysteria in the present mobilization among selected 
men. In cases of this kind organic disease of the verte- 
brae can and should be excluded, if necessary, by the X 
ray. In some cases moral suasion may suffice to demon- 
strate the stiff back is hysterical. Anesthesia can not be 
employed without consent of the registrant. 

XXm. DEGREE OF DEFICIENCY FOR DISQUALIFICATION. 
Regulations for the Local Board. (Section 186, S. S. R.) 

In these regulations the standards for unconditional Doubtful cases, 
rejection which places the registrant in the class physi- 
cally deficient and not physically qualified for military 
service are clearly defined. When the Local Board i3 
in any doubt, the registrant should be referred to the 
Medical Advisory Board. The attention of Local Boards 
and examining physicians is called to paragraph 3 of 
Section 123, page 64, after the side heading, Where Held 
Disqualified, which is as follows : 

If the registrant is held to be physically dis- 
qualified by the examining physician, the Local 
Board shall, unless it decides by unanimous vote 
that the disqualification is so obvious as to leave 
no room for reasonable doubt, send the registrant 
before such Medical Advisory Board in the man- 
ner just provided. 

This shows that there must be a unanimous vote of the 
Local Board to disqualify the registrant and the dis- 
qualification must be so obvious as to leave no room for 
reasonable doubt. 

The object of this ruling has already been given. 
(C. S. S. R. No. 3, Jan. 28, 1918.) 

Regulations for the Medical Advisory Board. 

The duty of the Advisory Board is plainly indicated 
in the examination and report to the Local Board upon 
the registrants referred to in Section 186 in the regula- 
tions for Local Boards. 

XXIV. TEMPORARY DEFECTS. 



Regulations for the Local Board. (Section 187, S. S. R.) 

Registrants confined to their homes, or hospitals, or Postpone- 

° . 7 r 1 ment of exanuna 

who present themselves with some temporary defect the tion - 
result of an acute disease, injury, or operation, or who 



98 

are waiting for operation, should be granted a reasonable 

delay for completing the physical examination. 

investigation. j^\ f these cases should be thoroughly investigated by 

the phycician on the Local Board. 

inf/Sn!™ 1 exam * Registrants with contagious, communicable, reportable 

~ diseases should not be ordered before the Local Board 

eases! a s " for examination until they are discharged by the boards 

Diphtheria. rf ^^ 

Registrants recovering from diphtheria should not be 
ordered to the cantonments until two negative cultures 
have been obtained from the throat. In localities where 
there is no provision for this bacteriological work, con- 
sult the Medical Advisory Board. (C. S. S. R. No. 3, 
Jan. 28, 1918.) 

Regulations for the Medical Advisory Board. 

Registrants referred to the Advisory Board who pre- 
sent themselves with some temporary defect, the result of 
a recent acute disease, injury, or operation, the Local 
Board should be advised to grant a reasonable time for 
recovery before the final examination by the Medical 
Advisory Board is made. 
Throat cultures. When Local or Advisory Boards can not command the 
facilities at the hospital headquarters for making throat 
cultures of registrants recovering from an attack of 
diphtheria as directed in section 187 in the Regulations 
for Local Boards, the cultures from the throats of such 
registrants may be sent by mail to the Laboratories of the 
United States Public Health Service. When possible Mu- 
nicipal and State Health Laboratories should be utilized 
in the same way. 

The Medical Advisory Board may employ section 187, 
S. S. R., Temporary Defects, when they desire, to grant 
the registrant a reasonable delay for completing the 
physical examination when it is difficult or impossible 
to come to a definite conclusion when the registrant 
first presents himself to the Medical Advisory Board. 
Instances of this kind are clearly defined in paragraphs 
III to XVIII in these regulations to the Medical Ad- 
visory Board. 

Medical Advisory Boards in those districts in which 
the registrants must be sent to them from a distance, 
should suggest to their Local Boards to hold registrants 
under section 187, S. S. R., for a reasonable time and not 
to send them to the Medical Advisory Board until the 
examination can be completed within at most three days. 



99 

If possible, the examination should always be completed 
within one day. 

XXV. SPECIAL AND LIMITED MILITARY SERVICE. 

Regulations for the Local Board. (Section 188, S. S. R.) 

In view of the importance of a thorough investigation M^icai" Advls° 
and classification of registrants belonging to this group, ory Boards - 
Local Boards are required to refer all of such registrants 
to the Medical Advisory Board. 

The physician on the Local Board is urged to 
consult with the Medical Advisory Board about 
this group and familiarize himself with the specific 
regulations and information soon to foe given to 
the Medical Advisory Board concerning special and 
limited military service. (C. S. S. R. No. 3, Jan. 28, 
1918.) 

XXVI. APPENDIX. 

RULES OF PROCEDURE FOR MEDICAL ADVISORY BOARDS 
AND IMPORTANT SECTIONS OF SELECTIVE SERVICE 
REGULATIONS RELATING THERETO. 

RULES OF PROCEDURE. 

1. Read carefully the Selective Service Regula- 
tions (S. S. R.), particularly the following sections: 
25, 29, 43 (d), 44, 46, 122 to 128£, 137, 141, 182 to 188, 
197, 198, 200, 201, 203, 204, 208 and 215. For ready refer- 
ence all of these sections are reprinted in this appendix 
with the exception of sections 44 and 128 \ which are 
printed in the Preliminary Statement of this Manual, and 
except sections 182 to 188 inclusive, " Physical Examina- 
tion," (as amended January 28, 1918, and issued by the 
Provost Marshal General as " Changes No. 3" in a 
separate pamphlet), all of which are reprinted, at the 
proper places, in this Manual. 

2. Medical Advisory Boards shall consist of three or 
more physicians. The number of Medical Advisory 
Boards and the membership of existing boards may be 
increased as necessity may indicate. (See Section 29, 
S. S. R., printed below.) When a Medical Advisory 
Board believes that other boards should be created, or 
additional members added to existing boards, it should 
recommend the same to the Governor. 



100 

3. Each board should select one member as chairman, 
one as vice chairman, and one as secretary. Additional 
vice chairmen may be selected. 

4. Request to the Governor for authority to employ 
clerical assistance and incur other expenses should be 
made only when absolutely necessary. Do not incur 
any expense until authorized by the Governor. See Pre- 
liminary Statement in this Manual and see also Sections 
43 (d), 198, 204, and 208, S. S. R., printed below. Sta- 
tionery will be supplied by The Adjutant General. 

5. No communications concerning the business of Medi- 
cal Advisory Boards should be addressed to any Depart- 
ment or official in Washington. Except for their com- 
munications with Local Boards Medical Advisory Boards 
must address all official communications of every char- 
acter, whether reports, recommendations, or requests 
for instructions or for interpretations to the Adjutant 
General of the State, who will either respond thereto or 
transmit the same to the proper authority. See Pre- 
lhninary Statement in this Manual and also Section 25, 
S. S. R., printed below. 

6. Select a place as headquarters of the Board where 
sessions may be held and physical examinations con- 
ducted. Select preferably a hospital or similar institu- 
tion, where proper and careful examinations can be made. 
It ought not to be necessary to pay rental for such head- 
quarters; but in the event that no free quarters can be 
obtained, application must be made through the Adju- 
tant General of the State to the Governor for authority 
to incur expense for rent. All physical examinations 
and every part thereof should be conducted at head- 
quarters of the board, unless it should be necessary to 
resort to some other place for the use of apparatus which 
is not otherwise available. See Preliminary Statement 
in this Manual. Sessions of the board should be held at 
stated hours and as frequently as necessity demands — 
daily, if necessary. 

7. A majority of the board will constitute a quorum, 
except in cases of boards consisting of ten or more mem- 
bers, in which cases five members shall constitute a 
quorum. The board shall decide all disputed questions 
by vote. The chairman need not vote except to break 

a tie. 

8. It shall not be necessary for all or a majority of a 

board to be present at or participate in the examination 
of a registrant, but one or more members may be ap- 



101 

pointed as a subcommittee to make an examination and 
shall report to the board, who may pass on the report 
or may make or require a further examination, 

9. If clerks are employed they are to be on duty at 
place of meeting daily, except Sundays and legal holi- 
days, from 9 a. m. to 5 p. m., and shall keep all records 
and conduct all correspondence under the direction of 
the board. 

10. Any member of the board can sign Form 1010, 
reporting the result of physical examination by the Medi- 
cal Advisory Board, designating the signer as follows: 
"Chairman," ''vice chairman," "secretary," or "mem- 
ber." 

11. Form 1010 when completed by the Medical xld- 
visory Board will be returned in triplicate to the Local 
Board by which issued. If registrant has been exam- 
ined at the request of The Adjutant General, Form 1010 
when completed by the Medical Advisory Board shall 
be returned in triplicate to The Adjutant General. (See 
section 137 printed below.) 

12. No permanent record is required to be kept by 
Medical Advisory Boards except a minute book and a 
list of registrants whose examination is temporarily de- 
layed on account of temporary defects, as provided in 
this Manual. The Medical Advisory Board shall keep a 
minute book, using the following or substantially equiva- 
lent form, which is not supplied but must be written or 
typewritten, and kept in the possession of the board until 
order from the Provost Marshal General. 

Date of meeting Convened M. Adjourned M. 

Present (members of board). Arrived. Left. 



Business Transacted. 
dumber of cases referred by the local board 

Number finally acted on 

Number of cases referred by registrant or Appeal Agent 

Number finally acted on 

Number of cases referred by The Adjutant General 

Number finally acted on 

Number of cases transferred from Local Boards 

Number finally acted on 



102 

IMPORTANT SECTIONS OF SELECTIVE SERVICE REGULA- 
TIONS RELATING TO LEGAL ADVISORY BOARDS. 

The following are the important sections of the Selec- 
tive Service Regulations relating to physical examina- 
tions, Medical Advisory Boards, and procedure of the 
latter and of Local Boards. Sections 44, 128J, and 
182 to 188, inclusive, as amended January 28, 1918, are 
not reprinted at this place for the reason that they 
already appear at length in this manual. 

Section 25. Correspondence rules of the Office of the Provost 
Marshal General. 

Rule A. Except as specifically provided in these Regu- 
lations, all communications intended for the Provost 
Marshal General concerning the execution of the Selective 
Service Law within a State emanating from individuals 
within the State or from Local and District Boards or 
other officials engaged within any State in the execu- 
tion of the Selective Service Law must be directed to 
the Adjutant General of the State for reference to 
the Provost Marshal General. Correspondence sent 
in violation of this rule to the Office of the Provost Mar- 
shal General will be returned to the writer. 



Section 29. Governor to District State and Appoint Medical 
Advisory Boards. 

Each State shall be carefully districted with due 
regard to communication and hospital facilities for the 
erection of a number of Medical Advisory Boards com- 
puted with a view to the equitable and practical distribu- 
tion of the work of reexamination as provided herein 
and to the convenience of registrants and economy to 
the Government in sending registrants before such boards. 

To assist the Governor in this work, a member of the 
Officers' Reserve Corps of the Medical Department, will 
be ordered to active duty to report to the Governor for 
a sufficient time to accomplish this organization. The 
American Medical Association and the Medical Section of 
of the Council of National Defense have also offered their 
services to Governors in accomplishing this purpose. 
Members of Medical Advisory Boards will be nominated 
by the Governor and appointed by the President in 
accordance with instructions to be hereafter communi- 
cated to the Governors. 



103 

Section 43. Clerical assistance for State Headquarters and for 
District, Local, and Medical Advisory Boards. 

When authorized by the Governor, as prescribed in 
Sec. 198 hereof, there may be engaged and compensated 
at the rates of pay prescribed in this section clerical 
assistance as follows: 

(d) For Medical Advisory Boards: 

1. One Chief Clerk. 

2. One additional clerk. 

The rate of compensation for a chief clerk shall not 
exceed the rate paid for similar service under local law, 
in no case to exceed $100 per month. 

The rate of compensation for additional clerks shall 
not exceed the rate paid for similar service under local 
law, in no case to exceed, for not more than one additional 
clerk of any District, Local, or Medical Advisory Board, 
$80 per month; for all other clerks in addition to the 
chief clerk and one additional clerk, $60 per month. 

Section 46. Duties of lawyers and physicians generally. 

The selection and classification of men for military 
service is an undertaking that should be regarded as a 
systematized effort of the citizenry of the- whole Nation 
organized and compacted to meet the present emergency. 
Every citizen has a duty to give his best endeavor to the 
success of this undertaking according to his qualifications 
and talents. All lawyers and physicians should regard it 
as their duty to identify themselves with the Advisory 
Boards provided for in sections 44 and 45, and freely and 
without compensation to give their best service to the 
Nation. It is inconsistent with this duty for lawyers to 
seek clients for the purpose of urging and advocating 
individual cases in any other way than as disinterested 
and impartial assistants of the Selective Service System. 

Physicians will render a most valuable assistance by 
giving their services to Local Boards and to the Medical 
Advisory Boards provided in section 44 hereof. 

Section 122. Physical examination. 

Beginning on such date or dates as the Provost Mar- 
shal General shall hereafter fiK for the beginning of the 
physical examination of all or any number or proportion 
of registrants, and after a registrant has been placed in 
Class I by a District Board (regardless of any appeal to 
the President hi his case) or, if no appeal or claim is 
made before the District Board,, then after the lapsing of 



104 

time for appeal from the placing of the registrant in 
Class I by the Local Board, the Local Board shall mail to 
the last known address of any registrant placed in Class I 
a notice (Form 1009) to appear for physical examination 
at a time and place to be designated in said notice (which 
time shall be five days from the date of the mailing of the 
notice), and shall enter the date of mailing of said notice 
in Column 19 of the Classification List. 

Upon appearance of the registrant he shall be exam- 
ined as provided in Part VIII hereof, and the date of his 
examination shall be entered in column 20 of the Classi- 
fication List. The examining physician shall immediately 
enter his report and recommendation in triplicate on 
the report of physical examination (Form 1010), shall 
then and there inform the registrant of his conclusion as 
to whether the registrant is qualified or disqualified for 
.general military service or qualified for limited military 
service in some specified capacity, and shall forthwith 
submit his report to the Local Board. 

If the registrant is not satisfied with such conclusion, he 
shall then and there record, in the place provided on Form 
1010, a request to be sent before a Medical Advisory 
Board. Failure to make this request on the day the 
registrant is examined and informed of the examining 
physician's conclusion shall foreclose the right of the 
registrant to appeal the finding of the Local Board on 
the physical qualification of the registrant. 

The same procedure as to physical examination pro- 
vided in these regulations for registrants in Class I shall 
also apply to all registrants who have been placed in a 
class more deferred than Class I, so soon as the imme- 
diately preceding or earlier class has been exhausted by 
calls into the military service and not before, except as 
provided in sections 128, 149, and 150. 

Note. — Whether the examining physician of the Local Board is in 
doubt or not as to the physical qualification of a registrant for military 
service he shall nevertheless definitely report the registrant either as 
qualified or disqualified, and if he is in doubt as to such qualification 
or disqualification he may request to have the registrant sent before a 
Medical Advisory Board as prescribed in section 123. 

Section 123. Sending doubtful cases to a Medical Advisory 
Board. 

If the examining physician is in doubt as to whether the 
registrant is to be held for military service, or if the exam- 
ining physician finds the registrant to be qualified for 



105 

military service and either the Government Appeal Agent, 
the registrant, or two members of the Local Board, are 
dissatisfied with such finding, such examining physician, 
Government Appeal Agent, members of the Local Board, 
or registrant may apply to the Local Board to have the 
registrant sent before the nearest Medical Advisory 
Board (provided in sections 29 and 44 hereof) for an 
exhaustive reexamination. Such application shall be 
made by entering it in the place provided in Form 1010. 
Thereupon the Local: Board shall, unless it decides by 
unanimous vote that the case is one in which there is no 
room for reasonable doubt, immediately send the regis- 
trant before such Medical Advisory Board, forwarding to 
the Medical Advisory Board the examining physician's 
report (Form 1010) in triplicate and, where necessary, 
and when the registrant is not sent at his own request, 
furnishing the registrant with transportation and meal 
and lodging tickets for the time during which he will be 
before such Medical Advisory Board, in no case to exceed 
three days. 

If the registrant is held to be physically disqualified by 
the examining physician, the Local Board shall, unless it 
decides by unanimous vote that the disqualification is so 
obvious as to leave no room for reasonable doubt, send the 
registrant before such Medical Advisory Board in the 
manner just provided. 

Upon reference of a case from a Local Board as just 
provided, the Medical Advisory Board shall examine the 
registrant, record its findings in triplicate on Form 1010, 
and return all three copies of Form 1010 to the Local 
Board, with the conclusion and recommendation in 
the case. 

Section 124. Finding by Local Board as to physical qualifica- 
tion. 

Upon receipt of the report and recommendation of 
the Medical Advisory Board as provided in section 123, 
or, if the case has not been sent to the Medical Advisory 
Board, then upon the receipt of the report of the examin- 
ing physician, the Local Board shall make its decision 
as to the physical qualification of the registrant. If the 
registrant is found physically disqualified for general 
military service, the Local Board shall cancel the cross 
mark (X) or cipher (0) which has already been entered 
in a classification column by drawing a red-ink line 
through such cross mark or cipher and shall enter the 



106 

classification of the registrant in Class V, column 12. If 
the registrant is found, in accordance with section 122 
hereof, to be physically disqualified for general military 
service, but qualified to perform special and limited 
military service, his place in the classification column 
shall not be changed, but the Local Board shall, with 
red ink, inscribe a bold circle around the cross mark 
(X) or cipher (0) in such classification column. (See 
Sec. 188, Part VIII.) 

While men found disqualified for general mili- 
tary service but qualified for special and limited 
military service are not placed in Class V, they are 
subject to induction into military service only 
when a special or specific call for men disqualified 
for general military service and qualified for special 
military service only is made. 

If the finding of the Local Board is not hi accord with 
the recommendation of the Medical Advisory Board, the 
Local Board shall make a special report to the District 
Board of its reason for rejecting the recommendation of 
the Medical Advisory Board. 

The Local Board shall, on the day of its decision as to 
the physical qualification of any registrant, mail to such 
registrant a notice (Form 1011) of the result of such de- 
cision and shall enter the date of such mailing in column 
21 of the Classification List (Form 1000). 

Section 125. Appeal from finding of Local Board as to physical 
qualifications. 

Within Ove days after the date of the notice prescribed 
in section 124 any registrant may make a claim of appeal 
to the District Board from the finding of the Local Board 
as to his physical qualification for military service. Claim 
of appeal shall be made by entering the claim in the place 
provided for that purpose on all three copies of the phys- 
ical examination report (Form 1010). Xo registrant 
may make a claim of appeal unless, upon being notified 
of the examining physician's finding as to his physical 
qualification, as prescribed in section 122, and before final 
decision by the Local Board, such registrant shall have 
entered an application to be sent before a Medical Advi- 
sory Board, as provided in section 122. The Government 
Appeal Agent may make a claim of appeal on behalf of the 
United States at any time, but ordinarily he shall not do 
so when the decision of the Local Board follows the rec- 



107 

ommendation of the Medical Advisory Board. He shall 
always do so when such is not the ease. 

Immediately upon filing of an appeal from the decision 
of the Local Board as to physical qualification, the Local 
Board shall transmit to the District Board all three 
copies of the record of physical examination (Form 1010) 
in the case, together with any additional evidence as to 
physical qualification which may have been submitted 
to the Local Board, and shall enter the date of forward- 
ing such record in column 22 of the Classification List 
and in the place provided on the Cover Sheet. 

Section 128. Action by District Board upon appeal as to physi- 
cal qualification. 

In considering a case appealed on the ground of 
physical qualification, the District Board shall neither 
conduct any new physical examination nor shall it re- 
ceive or consider any evidence which was not considered 
by the Local Board, but shall, upon consideration of the 
record sent to it as prescribed in section 125, either affirm, 
modify, or reverse the decision of the Local Board and 
promptly enter its finding on all three copies of Form 
1010, and immediately return the same to the Local 
Board. 

Note. — Attention of District Boards is invited to the fact that 
registrants appealing the result of their physical examination have 
already been twice examined, one of which examinations was the 
most thorough that could reasonably be provided in the community, 
and that before induction into military service they will again be 
exhaustively examined at a mobilization camp. 

Section 127. Procedure of Local Board on return of physical 
examination record from District Board. 

If the action of the District Board on appeal as to 
physical qualification changes or affects the classification 
of the registrant, the Local Board shall make the neces- 
sary changes in the Classification List. Whether the 
action of the District Board changes or affects the Classi- 
fication by the Local Board or not, the Local Board shall 
mail to the registrant a notice (Form 1011) of the result 
of the decision by the District Board, and shall enter the 
date of mailing of such notice in column 23 of the Classifi- 
cation List. 

Section 128. Physical examination of persons not in Class I. 

Local Boards may, upon the application of registrants 
in Classes II, III, or IV, examine such registrants physi- 
cally, pass upon their physical qualifications and, if they 



108 

are found to be permanently disqualified, to classify them 
in Class V. This is not a right of the registrant, but it is a 
privilege that may be accorded by the Local Board where 
the according of the privilege will not interfere with the 
prompt and orderly execution of the Selective Service 
Law. 

Section 137. Delinquents reporting to Adjutant General of the 
State within five days after induction into military service. 

If the delinquent reports to the Adjutant General of 
the State within five days after the date set for induction 
into military service, such Adjutant General shall order 
him to report to the nearest Medical Advisory Board or to 
any examining physician of a Local Board for physical 
examination, and shall defer reporting him to The Ad- 
jutant General of the Army until the result of such exami- 
nation is known. The Medical Advisory Board or such 
examining physician shall forthwith examine him and 
report the result (Form 1010) to the Adjutant General 
of the State. If the delinquent is found qualified for 
military service, he shall be ordered by the Adjutant 
General (Form 1019) to report forthwith to his Local 
Board for military duty and immediate transportation to 
a mobilization camp. Where it is impracticable to 
order the delinquent to report to his own Local Board, he 
may be ordered to report to another Local Board, where- 
upon the Adjutant General shall notify the delinquent's 
Local Board of the order and the case shall thereafter be 
treated as prescribed in section 148. 

No report is necessary to The Adjutant General of the 
Army in this case, but the Adjutant General of the State 
shall make a full report of all circumstances of the case 
in a letter addressed to the Commanding Officer of the 
mobilization camp, but sent to the delinquent's Local 
Board, together with the order of induction into military 
service (Form 1014), the order to report to such Local 
Board for military duty, and three copies of the report 
of the Medical Advisory Board or examining physician 
(Form 1010). The Local Board shall forthwith send the 
man to the mobilization camp in the usual manner, in- 
closing with Form 1029 the special report of the Adju- 
tant General of the State, the order of induction into 
military service (Form 1014), the order to report to the 
Local Board for military duty (Form 1019), the report of 
the Medical Advisory Board in duplicate, and a copy of 
the delinquent's registration card in duplicate. 



109 

If the delinquent is found to be disqualified for military 
service, the xidjutant General of the State shall report 
the case to the Commanding Officer of the mobilization 
camp direct, by letter, inclosing copies of the order of 
induction into military service (Form 1014) and the 
report of the Medical Advisory Board or examining 
physician. Such Commanding Officer shall, in his 
discretion, forthwith order the delinquent discharged 
from military service or shall order him before a court- 
martial, as the interests of the service may require. 

Section 141. Transfer of physical examination. 

A registrant who is so far distant from his home when 
called to report to his Local Board for physical examina- 
tion or when his physical examination is imminent as 
to make it a hardship for him to report may, at his own 
expense, request of his Local Board, by mail or telegram, 
permission to be examined by the Local Board to which 
he is nearest (naming it). Upon receipt of such a re- 
quest the Local Board of origin shall mail to the regis- 
trant an order to report to such Local Board of transfer 
for physical examination (using Form 1022 but making 
the necessary correction thereon) and to the Local 
Board of transfer a request that he be so examined 
(using Form 1022A). Thereupon the Local Board of 
transfer shall physically examine the registrant, and 
thereafter the procedure in regard to the registrant 
w T hose physical examination has so been transferred 
shall be the same as if he were originally a registrant 
of the Local Board of transfer. After all such procedure 
is completed the Local Board of transfer shall return 
to the Local Board of origin all three copies of Form 1010, 
with a report of its finding and the report, if any, of the 
Medical Advisory Board, and the report, if any, of the 
finding of the District Board of the jurisdiction of 
transfer. 

Section 197. Allowance of clerical assistance to be regarded as a 
maximum. 

The allowances of clerical assistance and compensation 
•thereof as prescribed in section 43 should be regarded as 
maximum limits, and every effort should be made by all 
concerned in the execution of the Selective Service Law to 
keep the expenses of the Government in the emergency 
down to the absolute minimum consistent with efficient 
service. L T ncompensated and volunteer service should be 
40712 6 — 18 8 



110 

encouraged and accepted. The great task of segregating 
and elassifjang registrants may be made very much easier 
for members of Local and District Boards if clerical 
assistance is utilized to the fullest extent in preparing and 
segregating Questionnaires for the consideration of the 
Board. Much of this preliminary work can be done by 
volunteer clerical assistance in the evening and every en- 
couragement should be extended to patriotic citizens, 
women as well as men, to assist in this work. 

Section 198. Authority for civilian clerical assistants. 

The form of authorization required to be made by the 
Governor of the State before a claim for salary of a civilian 
clerk for a Local or District or Medical Advisory Board, or 
for State Headquarters, may be paid will be found in sec- 
tion 306 but no printed forms will be furnished. The 
Governor shall not authorize any allowances or compen- 
sation in excess of the allowances and compensation fixed 
in section 43, nor in excess of that authorized by the 
law of the State, or that usually paid for similar serv- 
ices in the State. The number of the authorization 
should be entered in the place provided on every voucher 
on which a salary is paid. 

This authorization will be made in triplicate. One 
copy will be sent to the Board or office, one copy will be 
sent to the Disbursing Officer and Agent for the State, and 
the original will be sent to the Provost Marshal General. 
The original only is required to be signed. 

Section 200. Travel. 

The Provost Marshal General and, when authorized by 
the Provost Marshal General, the Governors of the several 
States may direct any person to travel when such travel 
is necessary in the execution of the Selective Service Law. 
District Boards by resolution of the Board may direct 
members and employees of the Board to travel when such 
travel is necessary in the execution of the Selective Service 
Law. 

Travel must, when such means of transportation is 
available or less expensive, be performed by common 
carrier. 

When travel is performed in compliance with orders 
issued as authorized in this section, cost of transporta- 
tion and Pullman accommodations over the shortest 
usually traveled route will be allowed and payment may 
be made of a per diem of $4 in lieu of subsistence while 



Ill 

traveling, and while the person ordered to travel is 
required by duty to be absent on duty from the city in 
which such person resides. 

When travel includes fractional parts of a day, the 
allowance for such fractional parts shall be $1 for each 
six hours or major fractional part thereof. 

Section 201. Travel orders. 

All orders for travel must state that the travel is neces- 
sary in the public service and in the execution of the 
Selective Service Law. 

The proper forms for travel orders will be found in 
sections 307 and 308, but no printed forms will be 
furnished. 

Section 203. Certain officers and agents for whom no com- 
pensation is provided. 

The service of members of Medical Advisory Boards, 
prescribed in section 29, of members of Legal Advisory 
Boards, prescribed in section 30, and of the Government 
Appeal Agents, prescribed in section 47, shall be uncom- 
pensated. 

Section 204. Clerical assistance. 

Clerical assistance for the division of the Office of the 
Adjutant General or other administrative department 
at State Headquarters and of District, Medical Advisory, 
and Local Boards shall be procured and compensated as 
prescribed in section 43 of these regulations. 

Section 208. General Expenses. 

The Provost Marshal General may authorize such 
lawful expenditures as he may deem necessary in the 
execution of the Selective Service Law. 

Section 215. Traveling expenses. 

Payment for traveling expenses will be made on War 
Department Form No. 350A, on which all blank spaces 
below the words "The United States, To 77 will be filled 
in down to the check notation. Each voucher shall be 
accompanied by a copy of the order of the Provost 
Marshal General or Governor, or of the resolution of the 
District Board directing the travel, which resolution shall 
contain a statement that the travel directed is neces- 
sary in the public service and in the execution of 



112 

the Selective Service Law; and a statement showing 
the following data: 

Means of transportation. 

Time of departure from permanent station. 

Time of arrival at temporary station. 

Time of departure from temporary station. 

Time of arrival at permanent station. 
If transportation other than common carrier as used, a 
certificate should be attached showing the fact that com- 
mon carrier was not available or was more expensive, the 
distance traveled, and the fact that the amount claimed 
is that usually charged for similar services in the same 
locality. 

C 



J 



